CAMP FOSTER, Okinawa — To ensure beneficiaries are getting all they’re entitled to, Tricare is spreading the word about the proper way to file a claim when treatment is received outside the military medical realm.
The first step to receiving any care outside a military treatment facility for Tricare patients is getting a referral from the primary care manager, according to Arlita McClintock, former Tricare marketing representative.
If care is received without a referral, the Tricare point-of-service option will apply, meaning it will cost the patient.
The rules apply mostly to nonemergency care; Tricare generally will cover emergency care with or without a referral.
Only those enrolled in Tricare Prime — Tricare Extra and Standard patients aren’t covered — are able to seek non- emergency services without referrals under the POS option, according to Brandie Morse, Tricare enrollment specialist at U.S. Naval Hospital Okinawa. She said there is an annual deductible of $300 for an individual and $600 for a family under the POS option.
Once the deductible is met, the patient’s cost will be 50 percent of the Tricare allowable charge plus any additional charges from non-network providers.
McClintock said that once a referral is obtained, patients should visit their military facility’s health benefits adviser to receive all the required documents: DD Forms 2161, Referral for Civilian Medical Care; 2642, Tricare Claims Form; and as needed, 2527, Statement of Personal Injury.
Once care is received, the health benefits adviser can help the beneficiary file the claim and can explain the entire process from start to finish, Morse said.
If the adviser receives the bill or receipt, he or she will file the claim for the patient to Wisconsin Physician Services, the subcontractor that files all claims for Tricare’s Western Pacific Region. If the patient receives the paperwork, he or she can take it to the adviser, who will help file the claim.
Morse said that if a patient is referred to an approved Tricare doctor, the doctor’s office usually will file the claim for him or her, unless the office specifies that it can’t.
If care is received without a referral, McClintock said, the patient must file the claim, which must include DD Form 2642 and an itemized bill with the patient’s name, hospital name, address, phone number, date of service and description of each service.
Once the process is complete, McClintock said, Tricare will mail the beneficiary an explanation of benefits and/or a check for reimbursement.
She said if the beneficiary wants to be paid in U.S. currency, he or she must note that on the claim before it’s filed; otherwise, the reimbursement will be paid in local currency.
For more information on filing a claim, visit your local Tricare service center or your medical facility’s health benefits adviser.
