15 PERCENT RULE
Under federal law, authorized health care providers who do not participate in Tricare can charge no more than 15 percent above what Tricare allows to be charged.
For example, if Tricare Standard allows a maximum charge of $100 for a visit to an authorized specialist, the specialist cannot charge a Tricare Standard patient more than $115. The patient is responsible for the usual cost shares and deductible, and most also are responsible for the extra 15 percent charge. Tricare pays the 15 percent for Tricare for Life users and for family members of reservists activated for more than 30 days.
Any patient billed more than 15 percent should show the provider the explanation of benefits or statement of how much Tricare will allow. If the provider does not correct the bill, the patient should contact the claims processor, who will ask the doctor to comply. If that fails, Tricare headquarters will contact the provider and ask for justification for the higher bill. Unless the higher bill can be justified, the doctor has 30 days to refund the excess charge or stop billing the patient. Health care providers who do not comply may lose their Tricare authorization.
Patients can waive this rule if they want to stay with a particular doctor.
When Tricare denies a claim, a beneficiary may take further action. If Tricare says the claim was denied as not medically necessary, the beneficiary first should ask the managed care contractor to reconsider. The request must be made within 90 days of the date on the denial statement and include a letter explaining why the beneficiary thinks the care should be covered, along with a copy of the denial statement.
The contractor’s second decision is due 30 days from the time the letter is received. If coverage again is denied based on medical necessity, the beneficiary has 90 days to appeal to the Tricare national quality monitoring contractor, a group independent of the managed care contractor.
That group’s decision is final if the disputed amount is less than $300. If it’s $300 or more, another appeal may be filed with the Tricare Management Activity.
When a claim is denied based on policy interpretation, a beneficiary or provider may first ask the contractor to reconsider. The request must be made within 90 days. Rejected claims may be appealed to the Tricare Management Activity if the amount is at least $50. A subsequent appeal may be made to that office if the disputed amount is at least $300.
Ultimately, a Tricare user can file a lawsuit to try to have the claim paid after all other appeals have been exhausted.
Military patients should ask civilian doctors not in a Tricare Prime or Extra network if they are authorized providers under Tricare Standard. Seeing an unauthorized provider will result in the denial of claims, even if the treatment is normally covered by the program.
Tricare claims are handled by health insurance companies and claims adjustment companies under Defense Department contracts. Families with private health insurance must submit claims to those companies first. When that insurer has paid, a claim then can be filed with the regional Tricare contractor.
There is no deductible for inpatient treatment using Tricare at civilian hospitals.
Tricare Prime has no outpatient deductible if care is received at a military treatment facility or a civilian provider in the Prime network. Under Prime’s point-of-service option, however, deductibles for outpatient care from providers not in the network are $300 for an individual and $600 for a family. After the point-of-service deductible is paid, Tricare will cover only 50 percent of the amount it allows to be charged.
Tricare Extra and Standard have annual deductibles for outpatient care. With each new fiscal year, the deductible must be met again. An electronic system tracks how much has been paid in co-payments and toward the annual deductible.
People who buy prescription drugs at retail stores outside the Tricare network also pay deductibles of $150 for an individual or $300 for a family. Enlisted members in paygrades E-4 and below pay lower deductibles: $50 for an individual, $100 for a family. Prime enrollees pay the point-of-service deductible.
DENTAL — INPATIENT
For dental care related to hospitalization, patients must get approval from their regional Tricare contractor before receiving treatment. Send a statement from a doctor (if one is involved) about the condition, along with a statement from the dentist saying what care is needed, why and how much it will cost. Requests should be made at least 30 days before scheduled treatment.
Hospice care provides various kinds of home and inpatient care for terminally ill patients. Tricare offers a hospice benefit that gives patients with six months or less to live several episodes of care: two initial 90-day periods and an unlimited number of subsequent 60-day periods. There is no deductible.
Tricare beneficiaries generally can get inpatient care at civilian hospitals without prior approval from a military facility. However, beneficiaries who use Standard or Extra and want to receive nonemergency inpatient mental health care at a civilian facility must first check with the nearby military hospital to see if the care can be provided there. If it cannot, the hospital will issue nonavailability statement allowing the patient to use a civilian facility.
If a patient receives inpatient mental health care without obtaining the nonavailability statement, Tricare won’t share the costs, unless there are extenuating circumstances that prevented someone from getting a nonavailability statement. Acute inpatient care for mental illness is covered on emergency and nonemergency bases. For emergencies and life-threatening disorders, call 911 and notify Tricare after admission; a physician’s referral is needed for acute inpatient programs in nonemergency situations.
Patients do not need nonavailability statements if they have Medicare or another health insurance that pays first.
Prime participants do not have to get nonavailability statements for any kind of care. People enrolled in Prime must consult their primary care manager to learn where they can be treated.
People who have health coverage in addition to Tricare must file claims first with that plan, which is the primary payer.
Payment from the primary plan plus Tricare may cover 100 percent of the bill, even after applying the usual cost-sharing requirements. Tricare pays nothing if coverage by the first payer exceeds Tricare’s maximum allowable charge.
Tricare users eligible for Medicare are in a similar situation: Medicare must be used before Tricare will pay benefits. Federal law establishes the order of payment. There are two exceptions:
♦When second coverage is Medicaid, Tricare pays first.
♦When the patient’s other insurance is specifically designated as a Tricare supplemental plan, Tricare pays first.
Claims for job-related illnesses and injuries are paid by workers’ compensation programs and are not covered by Tricare Standard. When workers’ compensation is exhausted, Tricare may be used.
A doctor who participates in Tricare accepts as full payment the amount Tricare allows for the particular service or supply. A doctor who does not participate is refusing to accept what Tricare allows as payment in full.
Doctors who are not in Tricare networks are free to decide when or if they will participate in Tricare Standard. The fact that doctors agree to accept Standard rates for one procedure does not obligate them to do so the next time a patient receives care.
Even if the doctor does participate, patients still must pay the deductible, co-payment or cost share and any service or supply not covered by Tricare.
Certain surgical, diagnostic and treatment procedures require pre-authorization from the managed care contractor in order for Tricare to pay for it. Check with local contractors for details.
PRIME SERVICE AREA
A prime service area is an area defined and mapped within proximity to military treatment facilities, installations affected by base realignment and closure, and other areas. Minimum government standards for military treatment facility PSAs and base realignment and closure PSAs are geographically defined by ZIP codes that create a radius of about 40 miles from the treatment facility or BRAC installation.
Military treatment facility enrollment areas are within a 30-minute drive of a treatment facility.