A primary care manager (PCM) is a nurse assigned to a sponsor and is part of the TRICARE provider network. TRICARE Standard provides beneficiaries with the greatest freedom in selection of civilian providers, yet is the most expensive.

Chapter 16

The TROs manage the TRICARE contracts in each region. This responsibility includes: Ensuring network quality and adequacy; resolves provider issues.

This preview shows page 1 – 3 out of 4 pages. Beneficiary Services Representatives provide information about using TRICARE and assist with other administrative Beneficiary Services Representatives provide information about using TRICARE and assist with other administrative matters.

Tricare (styled TRICARE), formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.

one year

Health Plans

• TRICARE Prime.
• TRICARE Prime Remote.
• TRICARE Prime Overseas.
• TRICARE Prime Remote Overseas.
• TRICARE Select.
• TRICARE Select Overseas.
• TRICARE For Life.
• TRICARE Reserve Select.

You can file some overseas claims online: Overseas medical claims. Overseas TRICARE Retiree Dental Program claims.

If yes, then you can file your claims online.

1. Fill out the TRICARE Claim Form. Download the Patient’s Request for Medical Payment (DD Form 2642).
2. Include a Copy of the Provider’s Bill.
3. Submit the Claim.
4. Check the Status of Your Claims.

Age 65 or older. Under age 65 with certain disabilities. Any age with end-stage renal disease.

In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-child care.

A claim may be denied for several reasons. Many times it’s a simple error that you (if you submitted the claim) or your provider made when submitting the claim. See Claim Filing Tips for a list of common mistakes. If your claim is unpaid or denied, contact your claims processor.

Denied Claims

1. If your claim is unpaid or denied, contact your claims processor.
2. If your claim was denied because of incorrect filing, correct the error and resubmit the claim to your claims processor.
3. If you believe your claim was inappropriately denied, in whole or in part, you or another appropriate party may file an appeal.

To File a Medical Necessity Appeal:

1. Send a letter to your contractor’s address.
2. Include a copy of the EOB or other decision.
3. Include any supporting documents.
4. If you don’t have all the supporting documents, send the appeal with what you have.

The current appeal process provides for three levels of appeal: (1) reconsideration by the TRICARE contractor that issued the initial denial; (2) second reconsideration by the TRICARE Quality Monitoring Contractor, or the Defense Health Agency Appeals and Hearings Division (DHA Appeals); and (3) a hearing before an …

Q: How long do I have to submit my claim to TriWest? A: Providers should make their best efforts to submit claims within 30 days of rendering services. Initial claims submitted after more than 120-days will be denied for lack of timely filing.

Regions 1, 2 and 4, submit appeals and correspondence in support of a claim via mail to: TriWest/WPS Claims, PO Box 42270, Phoenix AZ 85080. Appeals must be submitted within 90 days of receipt of the Explanation of Benefits or Remittance Advice. Please submit each appeal separately. Do not combine appeals.

Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge or three years if overseas, but you are encouraged to send your claim form to TRICARE as soon as possible after you receive care.

In order to view status information, the National Provider Identifier (NPI) on your www.tricare-west.com account must match the billing NPI on the claim. If you do not have a www.tricare-west.com account, use the automated self-service tools at 1-844-866-WEST (1-844-866-9378).

If TRICARE pays first and then discovers you had other health insurance, TRICARE will take back any payments made. They will only reprocess your claim after your other health insurance does.

With a new year on the horizon, Tricare enrollment fees and copays will be changing in 2020. By law Tricare fees go up slightly every year. For retirees the cost bump is tied to the annual cost of living increase (COLA), while other fee increases are set ahead of time by Congress.

Survivors of regular deceased retired service members are required to pay the TRICARE Select enrollment fee. You are only exempt from paying the TRICARE Select enrollment fee if: You are an active duty family member (this includes transitional survivors), You are a survivor of an active duty deceased service member, or.

1, 2018, TRICARE Standard will be renamed TRICARE Select. Also starting in 2018, you will need to go through a formal enrollment process (signing an enrollment form) to participate in TRICARE Select. Currently, you have to enroll to get care under TRICARE Prime, but your ID card is all you need under TRICARE Standard.

For an individual plan, you’ll pay $12.50 per month or $150 annually. For a family plan, you’ll pay $25.00 per month or $300 annually. The catastrophic cap will increase from $3,000 to $3,500. Your TRICARE Select enrollment fees will apply towards your catastrophic cap.

Tricare Select – Retirees and their families can purchase Tricare Select. All retirees have to pay a deductible amount of $150 per individual (no more than $300 per family).

TRICARE Prime is managed care, TRICARE Select is described as a preferred provider network available to all non-active duty beneficiaries. The TRICARE official site reminds that active duty service members pay nothing out-of-pocket for approved care.

“For example, if you want a primary care manager to coordinate your care, TRICARE Prime might be right for you. If you would prefer more flexibility when picking specialty providers, consider TRICARE Select.”

TRICARE For Life is Medicare-wraparound coverage for TRICARE beneficiaries who have Medicare Part A and Medicare Part B, regardless of age or where you live. TRICARE For Life (TFL) provides comprehensive health care coverage. TRICARE pays after Medicare and OHI for TRICARE-covered health care services.

Note: Visit our Copayment and Cost-Share Information page for 2021 costs….