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TRICARE and Other Health Insurance
TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs or plans as identified by TMA.
TRICARE beneficiaries who have OHI do not need referrals or prior authorizations for covered services, except for those services listed in Figure 8.10, which require prior authorization even when OHI coverage exists. Figure 8.10 OHI: Services Requiring TRICARE Prior Authorization
- Adjunctive dental care
- Behavioral health services
- All nonemergency inpatient admissions for substance use disorder or behavioral health care services
- Partial hospitalization programs and residential treatment center programs
- Psychoanalysis
- Extended Care Heath Option (ECHO) services
- Home health services
- Hospice services
- Solid organ and stem cell transplants
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Additionally, if the OHI benefits are exhausted, TRICARE becomes the primary payer and additional referral/prior authorization requirements may apply. Since OHI status can change at any time, ask all beneficiaries about OHI, including National Guard and Reserve members and their families. If a beneficiary’s OHI status changes, update patient billing system records to avoid delays in claim payments. If you indicate that there is no OHI, but Humana Military’s files indicate otherwise, a signed or verbal notice from the beneficiary will be required to inactivate the OHI record.
When a TRICARE-eligible beneficiary has OHI, submit a claim using the guidelines found in Figure 8.11.
In some cases, the TRICARE Summary Payment Voucher/Remit will state, “Payment reduced due to OHI payment,” and there may be no payment and no beneficiary liability. The TRICARE cost-share (the amount of cost-share that would have been taken in the absence of primary insurance) is indicated on the TRICARE Summary Payment Voucher/Remit only to document the amount credited to the beneficiary’s catastrophic cap.
Figure 8.11 OHI Claim Guidelines
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| Identify other health insurance (OHI) in the claim form |
To identify OHI in the claim form:
- Mark “Yes” in Box 11d (CMS-1500) or FL 34 (UB-04).
- Indicate the primary payer in Box 9 (CMS-1500) or FL 50 (UB-04).
- Indicate the amount paid by the other carrier in Box 29 (CMS-1500) or FL 54 (UB-04).
- Indicate insured’s name in Box 4 (CMS-1500) or FL 58 (UB-04).
- Indicate the allowed amount of the OHI in FL 39 (UB-04) using value code 44 and entering the dollar amount.
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| Payment guidelines |
- If TRICARE is the secondary payer, submit the claim to the primary payer first. If the claim processor’s records indicate that the beneficiary has one or more primary insurance policies, submit explanation of benefits (EOB) information from other insurers along with the TRICARE claim.
- Humana Military will coordinate benefits when a claim has all necessary information (e.g., billed charges, beneficiary’s copayment, and OHI payment). In order for Humana Military to coordinate benefits, the EOB must reflect the patient’s liability (copayment and/or cost-share), the original billed amount, the allowed amount, and/or any discounts. If the EOB indicates that a primary carrier has denied a claim due to failure to follow plan guidelines or utilize network providers, TRICARE will also deny the claim.
TRICARE does not always pay the beneficiary’s copayment or the balance remaining after the OHI payment. However, the beneficiary liability is usually eliminated. The beneficiary should not be charged the cost-share when the TRICARE EOB shows no patient responsibility. Payment calculations differ by provider status as detailed below.
With TRICARE network providers and non-network providers that accept TRICARE assignment, TRICARE pays the lesser of:
- The billed amount minus the OHI payment
- The amount TRICARE would have paid without OHI
- The beneficiary’s liability (OHI copayment, cost-share, deductible, etc.)
With non-network providers that do not accept TRICARE assignment, providers may only bill the beneficiary up to 115 percent of the TRICARE-allowable charge. If the OHI paid more than 115 percent of the allowed amount, no TRICARE payment is authorized, the charge is considered paid in full, and the provider may not bill the beneficiary. If the service is considered non-covered by TRICARE, the beneficiary may be liable for these charges.
With all other providers, TRICARE pays the lesser of:
- 115 percent of the allowed amount minus the OHI payment
- The amount TRICARE would have paid without OHI
- The beneficiary’s liability (OHI copayment, cost-share, deductible, etc.)
When working with OHI, all TRICARE providers should keep in mind:
- TRICARE will not pay more as a secondary payer than it would have as a primary payer.
- Point-of-service cost-sharing and deductible amounts do not apply if a TRICARE Prime beneficiary has OHI. However, the beneficiary must have prior authorization for certain covered services (listed in Figure 8.10), regardless of whether or not he or she has OHI.
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TRICARE and Workers' Compensation
TRICARE will not share costs for services for work-related illnesses or injuries that are covered under workers’ compensation programs.
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