How TRICARE Works with Other Health Insurance
|Active Duty Service Members
Active duty service members (including activated National Guard and Reserve members) can't use other health insurance as their primary insurance. TRICARE is the primary payer and coordination of benefits with other insurance carriers does not occur.
Active duty service members who have other health insurance (OHI) require an approval from Health Net Federal Service, LLC (HNFS) for all services.
|All Other Beneficiary Categories
All other beneficiaries with OHI (excluding Medicare) only require a prior authorization for applied behavior analysis services.
The OHI must be used before TRICARE. Health coverage through an employer, association, private insurer, school health care coverage for students, or Medicare is always primary to TRICARE.
Exceptions are: Medicaid, State Victims of Crime Compensation Programs, Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA), the Maternal and Child Program, the Indian Health Service, and plans specifically designated as TRICARE supplements.
If your OHI changes, please update your OHI information. Losing or gaining OHI is considered a qualifying life event (QLE).
If you need immediate assistance with a prescription that denied due to OHI information, you may contact Express Scripts at 1-877-363-1303 for assistance.
How TRICARE Calculates Payment with Other Health Insurance
TRICARE requires coordination of benefits with OHI coverage. TRICARE does not always pay your OHI copayment or the balance left over after the OHI payment. However, you usually owe very little to nothing. The TRICARE payment calculation is based on the provider's status. Note: Most inpatient facilities have other calculations not listed below.
TRICARE Network Providers and Non-Network Providers Who Accept TRICARE Assignment (Participating)
TRICARE pays the lowest of:
- billed amount minus the OHI payment
- amount TRICARE would have paid without OHI
- amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)
Providers Who Do Not Accept TRICARE Assignment (Nonparticipating)
Nonparticipating providers may only bill the beneficiary up to 115 percent of the TRICARE allowed amount. If the OHI paid more than 115 percent of the allowed amount, no TRICARE payment is authorized, as the charge is considered paid in full and the provider may not bill the beneficiary. Otherwise, TRICARE pays the lowest of:
- 115 percent of the allowed amount minus the OHI payment
- Amount TRICARE would have paid without OHI
- Amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)
Staff Model HMOs, Group HMOs and Other Capitated OHI Plan Providers
When you are enrolled in one of these OHI plans, the provider group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans, you generally only receive a copayment receipt – an itemized bill or Explanation of Benefits (EOB) is not available.
In these cases, you submit a Beneficiary Claim Form DD2642 with a copy of the receipt and the copayment is considered the billed amount. Deductibles and cost shares are applied and you may not receive full reimbursement of your HMO copayment.
Important Things to Know
- All requirements of the OHI plan must be followed. If the OHI denies a claim because OHI authorization requirements were not followed or because a network provider was not used, TRICARE will also deny the claim and you will be responsible for the denied charges.
- The OHI must process the claim before TRICARE can consider the charges.
- If the OHI denies the claim for services not medically necessary, all appeal rights with the OHI must be used before TRICARE can process the claim.
- Services must be provided by a TRICARE network or non-network provider.