Jul 16 2009

TRICARE Claims Confusion?

Published by CDR Katherine O'Neill Tracy, USNR-Ret. at 2:29 pm under Health Care Benefits, Health Care Questions

Ever wondered how TRICARE Prime processes claims for emergency beneficiary care received while traveling outside of the Prime Service Area (PSA)?   Read below to get an account of one such claim.


Several weeks ago, I blogged about my college age son’s visit to the ER while traveling as a TRICARE Prime beneficiary in the post entitled Have TRICARE – Will Travel. I thought an accounting of the subsequent sequence of events might prove informative for some – so here goes.

It all started in the ER when my son provided his insurance information to receive care. He thought his part was finished. Much to his surprise, the provider billed him directly!

The provider’s billing statement gave him the option of providing TRICARE’s information as the insurer and responsible party for payment, which he did. And again, he thought he was done.

Not so fast – TRICARE processed the claim and sent my son a check for 115% of the TRICARE Maximum Allowable Charge (TMAC) because the ER was a non-network provider and did not accept assignment. The attached TRICARE Explanation of Benefits (EOB) went on to say if he had not already paid the provider to use the attached check to reimburse them for services rendered. Being an astute young man he noted the amount TRICARE paid was less than half the amount of the bill he received and wanted to know who exactly was to pay the remainder.

This provided one of those teachable moments. I mentioned he may want to look over the EOB. After reviewing the information, he indicated the EOB listed $0.00 for deductible, copayment, and cost share under the Beneficiary Liability Summary; but, it was not intuitively obvious how the remainder of the bill was to be paid.

Thinking perhaps he had overlooked something, I quickly scanned the EOB and from his viewpoint could readily see the confusion. It did not clearly state that the TMAC amount satisfied the claim. I knew this – but how would he know?

We took it one step further and called the TRICARE claims contractor number at the bottom of the EOB. They confirmed the TMAC amount paid the claim in full. Furthermore, they informed him the provider was prohibited, by law, from balance billing him for the remainder of the amount – case closed!

I wonder how many others have encountered a similar situation…

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One Response to “TRICARE Claims Confusion?”

  1. # James Cannonon 24 Jul 2009 at 9:29 pm

    Current administration plans will kill Tricare and Medicare; for the retired, Tricare becomes Medicare at 65. Congress wants to cut $500 billion out of Medicare which means that few or no doctors will accept Medicare payments for military retired. Already Tricare and Medicare payments are very low compared to the requested payment. My significant personal experience shows that most Tricare payments are anywhere from 10 to 33 percent of the doctor bill. There are some exceptions, but few and far between.

    Keep the pressure on Congress. The current healthcare reform is on the wrong track and will make things far worse for all Americans….

    Thank you,
    Jim