TRICARE How-To: Filing Claims and Reimbursements

FALLS CHURCH, Va. - Have you ever had to get care while traveling? Or maybe you've had to visit a non-network TRICARE-authorized provider who doesn't "participate." In these situations-and some others-you might need to file a claim with TRICARE to get reimbursed.

A medical claim is a paper or electronic form that you submit to TRICARE for reimbursement.

"All TRICARE network providers have agreed to participate on all claims. That means their office will always file claims for you, and TRICARE will pay them directly," said Jody Donehoo, chief of the TRICARE Customer Support Division at the Defense Health Agency. "But non-network TRICARE providers can choose not to participate on a case-by-case basis. Just be sure your non-network provider is TRICARE-authorized-ask them!"

If you're uncertain about the claims and reimbursements process, here are some common questions and helpful tips.

Q: What does it mean when a non-network provider doesn't participate on a claim?
A: If your provider chooses not to participate on a particular claim, you may need to pay the provider up front. You'll then need to file a claim with your TRICARE contractor for reimbursement.

You should know that non-network TRICARE-authorized providers are allowed to require payment up front when they see you. However, many providers will wait for payment until after they send you a bill or invoice.

Q: How do I get reimbursed for upfront payments?
A: A reimbursement is the money TRICARE pays back to you if you paid your provider out of pocket. Remember, if you pay up front for services, be sure to get a receipt so you can include it with your claim.

When you get your reimbursement and Explanation of Benefits, you should verify the amount you owed in the "patient responsibility" section of the EOB. If you paid more than this amount to your provider, contact your provider to request a refund of the overpayment. You may need to provide a copy of the EOB.

Q: When do I need to file my own claims?
A: As detailed in the TRICARE Choices in the United States Handbook, you'll need to file your own claims when you:

• See nonparticipating providers: If you see a non-network TRICARE-authorized provider who chooses not to participate on your claim, you'll need to file a claim to get reimbursed for your expenses. Check out Filing Claims to get started.
• Get care overseas: Different TRICARE plans have different rules for getting care when traveling overseas. If you need to file a claim for care you received overseas, you'll file the claim with the TRICARE Overseas contractor, International SOS.

Q: How do I avoid needing to file claims?
A: Follow these tips to avoid filing claims:

• Get care at a military hospital or clinic: Because military hospitals and clinics don't operate on a TRICARE claim basis, going to a military hospital or clinic is the best way to avoid filing a TRICARE claim.
• Use network providers: If you can't get an appointment at a military hospital or clinic, stick to seeing civilian TRICARE network providers whenever possible. They'll file claims for you, so you won't have to worry about paperwork. You'll just pay your cost-share, if applicable. (It's also good to note that all hospitals that participate with Medicare must participate with TRICARE.)
• Get a referral or pre-authorization: Depending on the care you need, you may need a referral, a pre-authorization, or both. These show that you've been approved for treatment before going to your appointment. Your primary care provider can give you a referral. You can get a pre-authorization from your TRICARE contractor. This upfront process helps ensure you get the care you need, and that your claims process will go smoothly later.
• Keep records: Save all your receipts and treatment documentation. Organized records can ease the process of filing claims.

Q: How do I file a medical claim?
A: To file a claim, follow these steps:

1. Gather documents: Collect all relevant documents, including itemized bills, receipts, and any other paperwork related to medical expenses.
2. Complete forms: Fill out the appropriate claim form.
3. Submit documents: Mail the completed claim form and supporting documents to the appropriate claims address, or submit online through your TRICARE regional contractor.
4. Follow up: After submitting your claim, keep an eye on its status. You can check online by region or call your regional contractor for updates.

For more information, visit Filing Claims, or contact your regional contractor.

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