There
Is a One Year Deadline to File TRICARE Claims
Since 06-02-05
From: Waspscpo@aol.com [mailto:Waspscpo@aol.com]
Sent: Thursday, June 02, 2005 7:10 AM
To: undisclosed-recipients
Subject: (no subject)
http://www.tricare.osd.mil/news/2005/news0518.cfm
Tricare News
There Is a One Year Deadline to File TRICARE Claims
June 1, 2005
No. 05-18
TRICARE beneficiaries who file their own claims should remember that, with few
exceptions, claims must be filed within one year of the date of medical service
or from the date of discharge from an inpatient facility. Beneficiaries also
have one year from the date they receive medication to file for reimbursement of
pharmacy claims. Additionally, the one-year filing deadline applies to those who
file on behalf of individuals with other health insurance (OHI).
The deadline applies to TRICARE Standard beneficiaries as well as to TRICARE
Prime enrollees who obtain emergency or urgent care outside of the TRICARE
region in which they are enrolled. TRICARE Prime and Extra providers are
required to file claims on a beneficiary's behalf, and must also meet the one
year requirement. TRICARE beneficiaries who use non-network pharmacies to obtain
their prescription drugs pay full price at the pharmacy and then must file a
claim to obtain reimbursement.
Beneficiaries have many options for obtaining a claim form (DD 2642): from a
TRICARE Service Center, Beneficiary Counseling and Assistance Coordinator or
Health Benefits Advisor at their military treatment facility; by mail from the
TRICARE Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043;
or online at
www.tricare.osd.mil/claims.
By law, other health insurance (OHI) held by TRICARE beneficiaries must be the
first payer for covered benefits, including covered pharmacy services. TRICARE
pays first, however, when prescriptions not covered by OHI are covered by
TRICARE or when OHI coverage is exhausted.
In either case, beneficiaries must obtain an Explanation of Benefits (EOB) from
the OHI indicating their OHI does not cover the medication or that the benefit
limits of the OHI have been reached. Beneficiaries must submit a DD 2642 form
with the EOB, a copy of the itemized bill and, if a drug claim, a copy of the
prescription to the appropriate TRICARE contractor for reimbursement. Exceptions
to the one-year timely claims filing deadline apply if one or more of the
following situations occur:
The beneficiary was TRICARE-eligible at the time of service, but eligibility was
not reflected on the Defense Enrollment and Eligibility Reporting System until
after the timely filing limit;
Retroactive preauthorization was received after the timely filing limit expired;
TRICARE Management Activity or the regional contractor made an administrative
error;
A legal guardian responsible for managing the affairs of a mentally incompetent
patient or a patient who is unable to communicate, was appointed after the
timely filing date was reached;
The provider submits the claim as a TRICARE-participating provider after
changing from a non-participating provider;
The patient submitted a claim to their OHI in a timely fashion and the insurance
plan was responsible for a delay beyond the one-year filing date; or
Medicare accepts TRICARE for Life claims as timely. For more information on
exceptions to the one-year timely claims filing deadline and for claims
requirements, beneficiaries may visit
www.tricare.osd.mil/claims. For additional information on where to file
claims, beneficiaries should go to
www.tricare.osd.mil, click on their specific TRICARE region, and obtain
information regarding the TRICARE Retail Pharmacy or the TRICARE Mail Order
Pharmacy, as appropriate.
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Tricare Help
Catastrophic cap limits your out-of-pocket costs
By James E. Hamby Jr.
Special to Navy Times
6 June 2005 Issue
Q. What is the Tricare catastrophic cap and how does it work? Are pharmacy
co-payments included in the cap?
A. Numerous studies show that people have a tendency to overuse free and
unrestricted medical services. To discourage the costs to the government of
doctor bills for every runny nose and pimple, yearly out-of-pocket costs for
beneficiaries were included when Congress created CHAMPUS (the forerunner of
Tricare) in 1966.
The following information applies only to Tricare Standard. It does not apply in
full to Tricare Prime, which has no deductible and no co-payment amount that
varies with the dollar amount allowed on the claim.
Tricare Standard’s deductible is $150 per person per year, with a maximum of
$300 per family no matter how many family members file claims. That applies to
Tricare Standard retirees, retiree family members and survivors of deceased
active-duty and retired members.
For active-duty family members, the $150 deductible is charged if the sponsor is
in paygrade E-5 or above. The deductible for those whose sponsor is in paygrade
E-4 or below is $50. Most active-duty families are under Tricare Prime or
Tricare Prime Remote and pay no deductible.
Under Tricare, these out-of-pocket beneficiary costs — the deductible and cost
share amounts — are limited in each fiscal year by the Tricare catastrophic cap.
When a Tricare claim is processed, the processing contractor assigns a “value”
to each medical service. All insurers do this — Tricare, Medicare and commercial
insurers. The amount usually is based on records of amounts providers have
charged for each medical service in the recent past, together with other factors
such as income differentials in various parts of the country, and even between
rural and urban places in the same area.
Additionally, Tricare has adjustment factors included that are found in Medicare
law. Commercial insurers don’t have to account for those factors. Under Tricare,
the final figure is called the amount allowed. It is almost always less than the
amount the provider billed.
Tricare bases its payment on the amount “allowed,” not on the amount billed.
For active-duty family members under Tricare Standard, Tricare first subtracts
any unsatisfied deductible on a claim, then subtracts 20 percent of the
remainder. That 20 percent is the patient’s cost share. Tricare issues a check
for the remainder.
That works out to this formula: “amount allowed minus unsatisfied deductible
minus cost share equals amount of payment.” It’s the same formula used by most
commercial insurers.
For retirees, retiree family members and survivors, the patient’s cost share is
25 percent (compared with 20 percent for active-duty family member).
Claims processors maintain a running total of the amounts each family member and
the family collectively pay in deductibles and cost shares during each fiscal
year (Oct. 1 to Sept. 30).
When an individual’s deductible total reaches $150, that family member will not
be assessed any more deductibles during the fiscal year. When a family’s
deductible payments hit $300, no more deductibles will be charged to the family
during that fiscal year. All out-of-pocket expenses for covered Tricare
services, including pharmacy cost shares, count toward the cap.
The amount of the catastrophic cap is $1,000 per fiscal year for an active-duty
family and $3,000 per fiscal year for a retiree family or survivor family. When
a family (regardless of size) or individual reaches the catastrophic cap amount,
no more deductibles or cost shares will be charged for the rest of the fiscal
year. Tricare will pay 100 percent of the amount allowed (not the amount billed)
through the end of that fiscal year.
At midnight each Sept. 30, every family’s catastrophic cap account reverts to
zero, and deductible and cost-share amounts begin to accumulate again toward the
new fiscal year’s catastrophic cap.
To sum up, the cap does not limit the amount Tricare pays for medical care;
rather, it is a limit on the amount the beneficiary has to pay each fiscal year
in deductibles and cost shares.
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Contributed,
YNCS Don Harribine, USN(ret)