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, or other programs/plans as identified by TMA. TRICARE beneficiaries who have OHI are not required to obtain referrals or prior authorizations for covered services, except in the case of the services listed in Figure 8.7, which continue to require prior authorization even when OHI coverage exists.
Figure 8.7 OHI: Services Requiring TRICARE Prior Authorization
(Effective April 1, 2009)
- 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
- 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.
You are encouraged to ask the beneficiary about OHI so that benefits can be coordinated. Since OHI status can change at any time, it is important to obtain this information from the beneficiary on a routine basis, including from family members of activated National Guard and Reserve members. If a beneficiary’s OHI status changes, make sure to 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.
Submitting OHI Claims
The EOB from the primary insurer may accompany your claim submission to PGBA. If you are not able to transmit the required information on your electronic claim include the following information:
- The amount paid by the other insurer
- A copy of the primary insurer’s EOB with TRICARE paper claims; the primary insurer’s EOB must contain the following:
- The definition of any “reason codes” utilized by the primary payer to describe how the claim was processed, when applicable
- Information on the action taken by the primary payer for each specific date of service and charges, when applicable
Claims submitted without the above information will be denied.
TRICARE Prime Point of Service Option
Point of service (POS) cost-sharing and deductible amounts do not apply if a TRICARE Prime beneficiary has OHI. However, it is required that the beneficiary have prior authorization for certain covered services (previously listed in Figure 8.7), whether or not the beneficiary has OHI.
Calculating Payments
Payments from the primary payer and TRICARE as the secondary payer will not collectively exceed the TRICARE-allowable charge. Providers may not collect any out-of-pocket costs from the beneficiary after the payment of the claim, unless TRICARE and the OHI combined have failed to pay one of the following:
- The negotiated rate (if a network provider)
- The TRICARE-allowable charge (if a non-network provider accepting assignment)
- 115 percent of the TRICARE-allowable charge (if a non-network provider not accepting assignment)
If the primary insurer has paid more than what TRICARE would have allowed for the service, then no additional payment will be made. The beneficiary should not be charged the cost-share when the EOB shows no patient responsibility. Refer to Chapter 4 of the TRICARE Reimbursement Manual.
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