TRICARE Reserve Select Handbook

Important Information
TRICARE Reserve Select Web Site: Reserve Affairs Web Site: Guard/Reserve Portal Address: TRICARE National Web Site: TRICARE Mail Order Pharmacy: TRICARE Retail Network Pharmacy: TRICARE North Region Contractor Health Net Federal Services, LLC (Health Net): Health Net Web Site: TRICARE South Region Contractor Humana Military Healthcare Services, Inc. (Humana Military): Humana Military Web Site: TRICARE West Region Contractor TriWest Healthcare Alliance, Corp.(TriWest): TriWest Web Site: 1-888-TRIWEST (1-888-874-9378) www.triwest.com 1-800-444-5445 www.humana-military.com 1-800-555-2605 www.healthnetfederalservices.com www.tricare.mil/reserve/reserveselect www.defenselink.mil/ra https://www.dmdc.osd.mil/appj/trs/index.jsp www.tricare.mil 1-866-DoD-TMOP (1-866-363-8667) 1-866-DoD-TRRX (1-866-363-8779)

TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific) Overseas Toll-Free Number: Overseas Web Site: 1-888-777-8343 www.tricare.mil/overseas

An Important Note About TRICARE Program Changes At the time of printing, the information in this handbook is current. It is important to remember that TRICARE policies and benefits are governed by public law. Changes to TRICARE programs are continually made as public law is amended. For the most recent information, contact your regional contractor or local TRICARE Service Center. More information regarding TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online at www.tricare.mil.

TRICARE Reserve Select
TRICARE Reserve Select (TRS) is a premiumbased health plan that qualified National Guard and Reserve members may purchase unless eligible for coverage under the Federal Employees Health Benefits program (FEHB). If either the member or spouse is eligible to purchase the FEHB then the member and family are not eligible to purchase TRS. We use the terms National Guard and Reserve throughout this handbook to include: • Army National Guard • Army Reserve • Navy Reserve • Marine Corps Reserve • Air National Guard • Air Force Reserve • U.S. Coast Guard Reserve TRS offers coverage similar to TRICARE Standard and TRICARE Extra, and a monthly premium will be charged. You will receive comprehensive coverage with access to TRICARE-authorized providers. Annual deductibles, cost-shares, and a catastrophic cap apply. You may access care from a military treatment facility (MTF) on a space-available basis only. You may fill prescriptions through the MTF, the TRICARE mail-order pharmacy, and TRICARE retail network and non-network 1 If you are enrolled in TRS, you may not participate in the following programs: • Special Supplemental Food Program • TRICARE Extended Care Health Option (ECHO) • TRICARE Global Remote Overseas (TGRO) • TRICARE Prime • TRICARE Prime Remote (TPR) • TRICARE Prime Remote for Active Duty Family Members (TPRADFM) • TRICARE Prime Overseas • TRICARE Puerto Rico Prime • TRICARE Reserve Family Demonstration Project • US Family Health Plan (USFHP) pharmacies. Costs for prescription medications vary depending upon the pharmacy option you choose and the medication’s availability on the uniform formulary. For more information about TRS coverage, visit www.tricare.mil/reserve/reserveselect. For more information about the National Guard and Reserve and the Selected Reserve, visit the Reserve Affairs Web site at www.defenselink.mil/ra.

Programs Not Available with TRICARE Reserve Select

Your TRICARE Regional Contractor
We often refer to your regional contractor throughout this handbook and describe differences in each region. In cases where there are regional differences, refer to the information specific to your region. Besides offering toll-free customer service telephone lines and Web sites, each regional contractor operates TRICARE Service Centers throughout the region, typically at or near military installations, which offer customer service support. The following descriptions of each TRICARE region include contact information for each regional contractor.

WEST

NORTH SOUTH

TRICARE North Region The TRICARE North Region includes Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin, and portions of Iowa (Rock Island Arsenal area), Missouri (St. Louis area), and Tennessee (Ft. Campbell area).
Regional contractor Phone Web site Health Net Federal Services, LLC (Health Net) 1-800-555-2605 www.healthnetfederalservices.com

TRICARE West Region The TRICARE West Region includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal area), Kansas, Minnesota, Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner, including El Paso), Utah, Washington, and Wyoming.
Regional contractor Phone Web site TriWest Healthcare Alliance Corp. (TriWest) 1-888-TRIWEST (1-888-874-9378) www.triwest.com

TRICARE Overseas TRICARE South Region The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area).
Regional contractor Phone Web site Humana Military Healthcare Services, Inc. (Humana Military) 1-877-298-3408 www.humana-military.com

TRS is available overseas. The TRICARE overseas areas include TRICARE Europe, TRICARE Latin America and Canada (TLAC), and TRICARE Pacific. The TRICARE South Region contractor, Humana Military, handles enrollment, billing, and customer support services for these overseas areas.
Regional contractor Phone Web site Humana Military Healthcare Services, Inc. (Humana Military) 1-877-298-3408 www.humana-military.com

2

TRICARE Europe includes Africa, Europe, and the Middle East. TLAC includes Canada, the Caribbean Basin, Central and South America, Puerto Rico, and the Virgin Islands. TRICARE Pacific includes Asia, Australia, Guam, India, Japan, Korea, New Zealand, and remote Western Pacific countries. TRICARE Service Centers (TSCs) can provide information about locating a provider or accessing health care in overseas locations. Contact the TRICARE Area Office in your overseas area to locate a TSC near you.

The U.S. Department of State provides several useful resources, including a Web site listing U.S. Embassies and Consulates. A TRICARE point of contact is located at each U.S. Embassy and Consulate. Locate a U.S. Embassy or Consulate at www.usembassy.gov.

TRICARE Area Office Contact Information
TRICARE Europe Phone Toll-free: 1-888-777-8343, Option 1 Comm.: 011-49-6302-67-7432 DSN: 496-7432 Fax E-mail Online Comm.: 011-49-6302-67-6374 DSN: 496-6374 teurope@europe.tricare.mil www.tricare.mil/europe tricare15@se.amedd.army.mil www.tricare.mil/tlac TLAC Toll-free: 1-888-777-8343, Option 3 Comm.: 1-706-787-2424 DSN: 773-2424 1-706-787-3024 TRICARE Pacific Toll-free: 1-888-777-8343, Option 4 Comm.: 011-81-6117-43-2036 DSN: 643-2036 Remote Sites: 011-65-6-338-9277 Comm.: 011-81-6117-43-2037 DSN: 643-2037 TPAO.CSC@oki10.med.navy.mil www.tricare.mil/pacific

3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Getting Care While Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Getting Care Overseas . . . . . . . . . . . .17 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 TRICARE Reserve Select Wallet Card . . . . . . . . . . . .22 Coordinating Benefits with Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Coverage for Newborns or Adopted Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Appealing a Decision .31 Filing a Grievance . . . . . . Covered Services. . . . . . . . . . . . . 21 Health Care Claims . . . . . . . . . . . . . . . . .16 Services or Procedures with Significant Limitations . . . .30 Updating DEERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Information and Assistance . . . . .30 Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Outpatient Services . . . . . . . . . . . . . . . . . . . . . . .26 When TRICARE Reserve Select Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Changes to Your Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table of Contents 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Clinical Preventive Services . .11 Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Finding a Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Third-Party Liability . . . .18 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Changes to Your TRICARE Reserve Select Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Overseas Claims . . . . . . . . . . . . . .30 Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 4 . . . . . . . . . . . . . . . . . . . .21 Pharmacy Claims . . . . . . . . . . . .8 2. . . . . .14 Maternity Services . . . . . . . . . .7 Care at a Military Treatment Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Prior Authorization for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Limitations. . . . . . . Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Qualifying for TRICARE Reserve Select .16 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Behavioral Health Care Services . . . . . . .27 TRICARE Reserve Select Survivor Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 5 . . . 7. . . . . .6. . . . . . . . . . . . . . . . see the inside back cover of this handbook. . . . . . . . . . . . . List of Figures . . . . . . . 36 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Sample Explanation of Benefits Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 9. . . . . . . . . . . . . 35 Glossary . . . . . . . . . . . 47 For information about your patient rights and responsibilities. . . . . . . . . . . . . . . . Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 10. . . 8. . . . . . .

mil/ProviderDirectory. if an orthopedic surgeon and a physical therapist are treating you. The regional contractors also have TRICARE network provider directories on their Web sites. Figure 1. Visits to a TRICARE network provider will cost you less out of pocket. and the provider will file claims on your behalf. which you may use to locate providers in each region. you are responsible for the full cost of care. TRICARE-authorized provider at any time. For example. and pharmacies.1 • TRICARE-authorized providers are those who meet TRICARE’s licensing and certification requirements and have been certified by TRICARE to provide care to TRICARE beneficiaries. If you see a provider who is not TRICARE-authorized. Some services will require prior authorization (discussed later in this section). 6 . call your regional contractor for assistance locating a provider. Note: For information about finding a provider overseas. ancillary providers (such as laboratories and radiology centers). To find a TRICARE network provider or a non-network. up to 15% above the TRICAREand to accept the TRICAREallowable charge for services. you’ll pay more out of pocket and may have to file your own claims. TRICARE-authorized provider. • If you visit a nonparticipating • Using a participating provider is provider. • Using a network provider is your best option. You allowable charge. With a non-network. visit the provider locator at www. Network Providers Non-Network Providers • Have a signed agreement with your • Do not have a signed agreement with your regional contractor. you may have to pay the your best option if seeing a nonprovider first and file a claim with network provider. TRICARE-authorized provider. If you do not have Internet access. (less any are responsible for paying this applicable patient cost-shares paid amount in addition to any by you) as payment in full for their applicable patient cost-share. regional contractor to provide care. one could be a TRICARE network provider and the other could be a non-network.tricare.1 describes the different types of providers. TRICARE for reimbursement. Participating • May choose to participate on a claim-by-claim basis Nonparticipating • Have not agreed to accept the TRICARE-allowable charge or file your claims. These include doctors. services. to accept • Have the legal right to charge you payment directly from TRICARE. • There are two types of TRICARE-authorized providers: Network and Non-network. You may use either a TRICARE network provider or a non-network. TRICARE Provider Types TRICARE-Authorized Providers Figure 1. Nonparticipating.Getting Care Finding a Provider With TRICARE Reserve Select (TRS) you may receive care from any TRICARE-authorized provider without a referral. • Have agreed (when participating) to file claims for you. hospitals. Ask if your health care provider(s) is a TRICARE network provider. • There are two types of non-network providers: Participating and • Agree to handle claims for you. TRICARE-authorized provider. see “Getting Care Overseas” later in this section.

and you will be assigned the lowest priority for receiving MTF care.2 TRICARE: The World’s Best Health Care for the World’s Best Military TRICARE Reserve Select TRS Member: John Q. usually located on or near a military installation. Prior Authorization for Care TRS Wallet Card (back) You may access care from any TRICAREauthorized provider you choose whenever you need it. that the absence of medical attention would result in a threat to the patient’s life. or psychiatric condition that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists.tricare. or other provider asks to see your insurance card. If you do not receive your TRS wallet card within four to six weeks of submitting your TRS Request form. MTF appointments are limited. If you require emergency care. but some services will require prior authorization. Emergency Care TRICARE defines an emergency as a medical.GETTING CARE SECTION 1 TRICARE Reserve Select Wallet Card You and each covered family member should receive (or may already have received) a TRS wallet card when your TRS enrollment is processed through the Defense Enrollment Eligibility Reporting System (DEERS). maternity. If your doctor.tricare.3 A military treatment facility (MTF) is a military hospital or clinic. durable medical equipment supplier. TRICARE Regional Contractor TRICARE Retail Pharmacy TRICARE Mail Order Pharmacy http://xxxxx/xxxxx/xxxxx/xxxxx. Care at a Military Treatment Facility TRS Wallet Card (front) Figure 1.mil/mtf. Some providers may call the regional contractor to obtain prior authorization for you. access the MTF Locator at www. This card is not a guarantee of coverage. pharmacist. TRS benefits are available from TRICARE-authorized providers and TRICARE Network providers. hospital. If you are admitted. Referrals are not required. you may present this card. or that the patient has painful symptoms requiring immediate attention to relieve suffering. that the patient requires immediate medical treatment.xxx xxx-xxx-xxxx xxx-xxx-xxxx 7 . Sample Effective Date: 01 Jan 2000 Covered Person: Susie Q. You may receive care at an MTF on a space-available basis only.xxx In EMERGENCY—dial 911 or go to the nearest emergency medical facility. limb. or sight. Coverage under TRS is separate from any medical coverage indicated on the military identification card. you may need to obtain authorization (depending on the type of care) by contacting your regional contractor. A prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care.mil AM S LE P Figure 1. contact your regional contractor for assistance. Sample The TRS identification number is the TRS member’s Social Security Number. AM S LE P xxx-xxx-xxxx xxx. call 911 or go to the nearest emergency room.xxxx. Pre-certification is required for inpatient mental health and selected regionally-determined procedures. TRS wallet cards contain key phone numbers and other information to assist you with your health care coverage. Prior authorizations must be obtained prior to services being rendered or within 24 hours of an admission. call your regional contractor or visit their Web site for assistance before seeking care. ww w. If you have questions about your authorization requirements. To locate an MTF.

as they may change periodically. Visit your regional contractor’s Web site or call their toll-free number to learn about your region’s requirements. contact the nearest overseas TAO for assistance before seeking care. or the nearest U.).” Then click on “TRICARE Claim Form (DD Form 2642). You may be required to pay non-network providers directly and file your claim with your regional contractor for reimbursement (See the Claims section of this handbook. Getting Care While Traveling While you are traveling.The following services* require prior authorization in all three TRICARE regions: • Adjunctive dental services • Extended Care Health Option (ECHO) services • Home health services • Hospice care • Nonemergency inpatient admissions for substance use disorders and behavioral health • Outpatient behavioral health care beyond the eighth visit each fiscal year (October 1– September 30) • Transplants—all solid organ and stem cell * This list is not intended to be all-inclusive. You should file the claim with the contractor in your home region. Each regional contractor has additional prior authorization requirements. TRICARE-authorized provider. Locate a U.S. Note: For overseas prior authorization information. Prior Authorization Requirements Overseas Since authorization requirements may vary by overseas area. In the right-hand navigation column. See Figure 3.” 8 .S.2.tricare. Embassy Health Unit for assistance in locating a provider.” in the Claims section of this handbook for TAO contact information. you may visit any TRICARE network provider or any non-network. see “Getting Care Overseas” later in this section. We recommend that you contact your TRICARE Service Center (TSC).gov.mil/claims. “Overseas Claims Addresses. You will find claim forms at www. TRICARE Area Office (TAO).usembassy. look for “Downloads. not in the region in which you received the care. Embassy or Consulate by visiting www. Getting Care Overseas You may receive care from any qualified host-nation provider without a referral.

and occupational therapy. physical. or psychiatric conditions that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists.GETTING CARE SECTION 1 Covered Services. and routine and non-routine medical services. and cardiovascular studies. This chart is not intended to be all-inclusive. For example. Generally covered if medically necessary and appropriate. or personal physician. or sight.1 provides coverage details for covered outpatient services. allergy tests and treatment. speech pathology services. diagnosis. diagnostic nuclear medicine. and Exclusions TRICARE Reserve Select (TRS) covers most care that is medically necessary and considered proven. in-home. maternity. All care must be provided by a participating home health care agency and be authorized in advance by the regional contractor. and medical supplies used within the office. Emergency Services Home Health Care Individual Provider Services Laboratory and X-Ray Services Prosthetic Devices and Medical Supplies 9 . COVERED SERVICES. that the patient may be a danger to self or others and requires immediate medical treatment. (Some exceptions apply. Duplicate items of DME that are essential to provide a fail-safe. transport or transfer of a patient primarily for the purpose of having the patient nearer to home. osteopathic manipulation. Covers part-time or intermittent skilled nursing services and home health services.g. and occupational therapy). accident scene.. and if prescribed by a physician for the specific use of the beneficiary. while other types of care are not covered at all. a portable oxygen concentrator may be covered as a backup for a stationary oxygen generator. e. Check with your regional contractor for additional information. In this case. and transfers between a hospital or skilled nursing facility and another hospitalbased or freestanding outpatient therapeutic or diagnostic department/facility. limb.) Generally covered if prescribed by a physician and if directly related to a medical condition. and medicabs or ambicabs that function primarily as public passenger conveyances transporting patients to and from their medical appointments. chemosensitivity assays and bone density X-ray studies for routine osteoporosis screening are not covered. Limitations. physical therapy. transfers between hospitals. rehabilitation services (e. family. LIMITATIONS & EXCLUSIONS SECTION 2 Outpatient Services: Coverage Details Service Ambulance Services Description Figure 2. Prosthetic devices must be FDA approved. However. and treatment by a specialist. Outpatient Services Figure 2. or that the patient has painful symptoms requiring immediate attention to relieve suffering. speech. Ancillary Services Durable Medical Equipment (DME) Covers certain diagnostic radiology and ultrasound. that the absence of medical attention would result in a threat to the patient’s life. Excludes ambulance service used instead of taxi service when the patient’s condition would have permitted use of regular private transportation. medical social services. “duplicate” means an item that meets the definition of DME and serves the same purpose but may not be an exact duplicate of the original DME item. friends. ambulance transfers from a hospital-based emergency room to a hospital more capable of providing the required care. there are special rules or limits on certain types of care.g. or other location to a hospital. consultation. Emergency services are covered for medical. Generally covered if prescribed by a physician. This section is not intended to be all-inclusive. outpatient office-based medical and surgical care. pathology and laboratory services.1 Covers emergency transfers to or from a beneficiary’s home. Covers office visits. life-support system are covered..

and hospital service. anesthesia. and substance abuse. and suicide risk assessment) Figure 2. or if not previously administered. cancer of female reproductive organs. skin. Coverage for human papillomavirus (HPV) vaccine provided for initial administration for girls age 11-12. Includes inpatient physical and surgical services. including influenza.2 Skilled Nursing Facility (SNF) Care Clinical Preventive Services Figure 2. Inpatient Services: Coverage Details Service Hospitalization Description Covers semiprivate room (and when medically necessary. meals (including special diets). alcohol.Inpatient Services Figure 2. necessary medical supplies and appliances. and exposure to certain infectious diseases. Figure 2. Covers semiprivate room.3 provides coverage details for covered clinical preventive services. human immunodeficiency virus [HIV] testing) and preventive therapy when at-risk (tetanus. and stress. animal bite. The following services may be covered if provided in connection with a visit for immunizations. occupational. Unlike Medicare. drugs and medications while an inpatient. operating and recovery room. Clinical Preventive Services: Coverage Details Service Health Promotion and Disease Prevention Examinations Description Office visits may be covered for the following services (subject to age and other criteria): • Cancer screening examinations and services (breast cancer. This chart is not intended to be all-inclusive. Rh immune globulin. safe sexual practices. laboratory tests. drugs furnished by the facility. and thyroid) • Infectious disease (tuberculosis screening. X-rays and other radiology services. blood pressure screening) • Body measurements (height and weight) • Vision screening • Audiology screening (only allowed under well-child services) • Counseling services expected of good clinical practice that are included with the appropriate office visit at no additional charge (dietary assessment and nutrition. oral cavity and pharyngeal.3 Other Health Promotion and Disease Prevention Services 10 . general nursing. as recommended by the Centers for Disease Control and Prevention (CDC). regular nursing services. Pap smears. mammograms. for girls age 13-26. colorectal cancer. TRICARE covers an unlimited number of days as medically necessary. and speech therapy. This chart is not intended to be all-inclusive.2 provides coverage details for covered inpatient services. including special diets. physical. special care units). cancer surveillance. and blood and blood products. tobacco. or examinations for colon and prostate cancer: • Cancer screening (testicular. including tuberculosis) • Genetic testing and counseling for certain clinical indications during pregnancy • Other: routine chest X-rays and electrocardiograms required for admission when a patient is scheduled to receive general anesthesia on an inpatient or outpatient basis Immunizations Covered for age-appropriate dose of vaccines. and necessary medical supplies and appliances. and prostate cancer) • Infectious diseases (Hepatitis B screening. physical activity and exercise. bereavement. meals. promoting dental health. accident and injury prevention. Rubella antibodies) • Cardiovascular disease (cholesterol screening.

Figure 2. immunizations.4 on the following page provides coverage details for covered behavioral health care services. The following types of behavioral health providers may be authorized providers under TRICARE: • Psychiatrists • Clinical psychologists • Clinical psychiatric nurse specialists • Clinical social workers • Certified marriage and family therapists with a TRICARE participation agreement • Pastoral counselors—with physician referral and supervision • Mental health counselors—with physician referral and supervision If you are unsure which type of provider would best meet your needs. includes office visits. This chart is not intended to be all-inclusive. After the first eight visits. contact your regional contractor for assistance.Clinical Preventive Services: Coverage Details (continued) Service Pap Smear School Physicals Description Covered as either a diagnostic or routine preventive procedure. Well-Child Care Covered from birth to age 6. TRICARE-authorized providers. For additional information about covered and non-covered behavioral health care services and how to access care. The human papillomavirus (HPV) Pap test is not covered as a routine screening Pap smear. Covered for children ages 5–11 if required in connection with school enrollment. and vision screening. prior authorization is required. Note: Annual school sports physicals are not covered. Behavioral Health Care Services You may receive your first eight behavioral health outpatient visits per fiscal year (October 1–September 30) without prior authorization from your regional contractor. COVERED SERVICES. contact your regional contractor. LIMITATIONS & EXCLUSIONS SECTION 2 11 . Remember to obtain care only from TRICARE network providers or non-network.

Exclusions Psychological testing is not covered for the following circumstances: • Academic placement • Job placement • Child custody disputes • General screening in the absence of specific symptoms • Teacher or parental referrals • Diagnosing specific learning disorders or learning disabilities * The fiscal year is October 1–September 30.Behavioral Health Care Services: Coverage Details Service Acute Inpatient Psychiatric Care Description Figure 2. in any combination of day. 12 . • Prior authorization from your regional contractor is required.or 45-day inpatient limit. authorization is required for continued stay.* • Patients age 18 and younger are limited to 45 days per fiscal year. Limitations • Limited to 60 treatment days (whether a full. Psychological tests are considered to be diagnostic services and are not counted against the limit of two psychotherapy visits per week. In emergency situations.4 Acute inpatient psychiatric care may be covered on an emergency or nonemergency basis.or 45-day limit. night. Psychiatric partial hospitalization provides interdisciplinary therapeutic services at least three hours per day. you must be under the care of a provider who is authorized to prescribe those medications. Prior authorization from your regional contractor is required for all nonemergency inpatient admissions. • Facility must be TRICARE-authorized. • Psychiatric partial hospitalization programs must agree to participate in TRICARE. evening. Medication Management If you are taking prescription medications for a behavioral health condition.* These 60 days are not offset by or counted toward the 30. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible. and weekend treatment programs.or partial-day treatment) in a fiscal year. Psychiatric Partial Hospitalization Psychological Testing and Assessment Covered when medically or psychologically necessary and provided in conjunction with otherwise-covered psychotherapy.* • Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30. Limitations • Patients age 19 and older are limited to 30 days per fiscal year. five days a week. Limitations Testing and assessment is generally limited to six hours in a fiscal year.

per fiscal year. or group sessions. • Admission primarily for substance use rehabilitation is not authorized. family. family. collateral.Behavioral Health Care Services: Coverage Details (continued) Service Psychotherapy Description Prior authorization is required after the first eight behavioral health outpatient visits per beneficiary. collateral.* Covered psychotherapy includes: • Individual. * The fiscal year is October 1–September 30. • RTC care is considered elective and will not be covered for emergencies. The duration and frequency of care is dependent upon medical necessity. COVERED SERVICES. • Care must be recommended and directed by a psychiatrist or clinical psychologist. • Facility must be TRICARE-authorized. • Inpatient psychotherapy is limited to five sessions per week in any combination of individual. LIMITATIONS & EXCLUSIONS SECTION 2 13 . and is not covered when the patient is an inpatient in an institution. conjoint. Limitations • Limited to 150 days per fiscal year* (may be waived if determined to be medically or psychologically necessary) Note: No qualified RTCs were available in overseas locations at time of printing. • Unless therapeutically contraindicated. family. or group sessions • Collateral visits • Play therapy (a form of individual therapy used with children) • Psychoanalysis (prior authorization from your regional contractor required) Limitations • Outpatient psychotherapy is limited to a maximum of two sessions per week in any combination of individual. • Prior authorization from your regional contractor is required. or group sessions. Residential Treatment Center (RTC) Care RTC care provides extended care for children and adolescents with psychological disorders that require continued treatment in a therapeutic environment. the family and/or guardian must actively participate in the continuing care of the patient either through direct involvement at the facility or geographically distant family therapy.

TRICARE Mail Order Pharmacy The mail-order pharmacy is your least expensive option when not using the MTF. or online. You may receive up to a 90-day supply for most medications delivered to your home for a small copayment. • Rehabilitation—Rehabilitation (residential or partial) is limited to 21 days per year or one inpatient stay in a facility subject to the DRG-based reimbursement system. Coverage and Limitations • Benefit period—Only three substance use disorder treatment benefit periods in a lifetime are covered (waiver possible in accordance with policy criteria). In a diagnosis-related group (DRG)-exempt facility. Go to www. you are limited to three benefit periods in your lifetime. Refills may be requested by mail. Complete the online registration form and follow the instructions for submission. 2. * The fiscal year is October 1–September 30. per benefit period. Visit www. Register online. Military Treatment Facility Pharmacy Prescriptions may be filled (up to a 90-day supply for most medications) at an MTF pharmacy at no cost as long as the medication is on the MTF formulary. Emergency and inpatient hospital services are considered medically necessary only when the patient’s condition is such that the personnel and facilities of a hospital are required. A benefit period begins with the first date of covered treatment and ends 365 days later.* Individual outpatient care for substance use disorder is not covered. To have a prescription filled. Coverage is limited to 60 visits per fiscal year. Register by phone. call 1-866-ASK-4PEC (1-866-275-4732). including detoxification. You are covered for up to 15 visits in a benefit period. Call 1-866-363-8667 (in the United States). If your pharmacist asks for your insurance card.” Then select “How to Register” in the left-hand navigation column. Pharmacy Services TRICARE offers comprehensive prescription drug coverage and several options for filling your prescriptions. you should provide your TRS wallet card. unless the limit is waived. 14 . detoxification services are limited to seven days per year. Note: All treatment for substance use disorders requires prior authorization from your regional contractor.tricare.Behavioral Health Care Services: Coverage Details (continued) Service Treatment for Substance Use Disorders Description A substance use disorder includes alcohol or drug abuse or dependence. Emergency and inpatient hospital services for detoxification. • Detoxification—If chemical detoxification is needed but does not require the personnel or facilities of a general hospital setting. and outpatient group and family therapy. and treatment of medical complications of substance use disorders do not count for purposes of establishing the beginning of a benefit period. All inpatient stays count toward the 30.or 45-day inpatient limit. phone. Registering for the mail-order pharmacy is easy: 1. you’ll need a written prescription. • Outpatient Care—Must be provided by an approved substance use disorder facility in a group setting. rehabilitation. TRICARE may cover services for the treatment of substance use disorders. stabilization. If overseas. regardless of the total services actually used within the benefit period. • Family Therapy—Outpatient family therapy is covered beginning with the completion of rehabilitative care. detoxification services are covered in addition to rehabilitative care. You should contact the MTF pharmacy to find out what is on the formulary and for specific details about filling prescriptions there.tricare.mil/pharmacy and click on “Filling Prescriptions.mil/pharmacy for pharmacy cost information.

S. LIMITATIONS & EXCLUSIONS SECTION 2 .mil/pharmacy and click on "Filling Prescriptions. Exceptions to established quantity limits may be made if the prescribing provider is able to justify medical necessity. Guam. see the Claims section of this handbook.mil/pharmacy and mail it to: TRICARE Mail Order Pharmacy P. or 90-day supply) of medication. and for drugs that require prior authorization or have quantity limits. visit www. 60-. For more information or to locate a TRICARE retail network pharmacy. and when a generic equivalent is available. you will be responsible for paying the entire cost of the prescription out of pocket. To convert by phone.) Quantity Limits and Prior Authorization TRICARE has established quantity limits on certain medications. To convert online. Puerto Rico. Generic Drug Use Policy It is DoD policy to use generic medications. you may register before placing your first order. Note: Retail network pharmacies are available in the United States. (For more information about pharmacy claims.” If you don’t have Internet access. Virgin Islands.O. Register by mail. your provider can fax or call in your prescriptions. If a generic equivalent does not exist. Brand-name drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to justify medical necessity for use of the brand-name drug in place of the generic equivalent. You may have to pay for the total amount first and then file a claim to receive a partial reimbursement from TRICARE after your deductible is met. and the U. TRICARE Retail Network Pharmacy You may have prescriptions filled (up to a 30day supply) at any pharmacy in the TRICARE retail network for a small copayment. whenever possible.tricare. If you have prescription drug coverage from another health insurance plan. 15 Non-Network Pharmacy Filling prescriptions at a non-network pharmacy is the most expensive option. For faster processing of your mail-order prescription. call 1-877-363-1433. For a general list of prescription drugs that are covered under TRICARE. call 1-866-DoD-TRRX (1-866-363-8779) or visit www.mil/pharmacy and click on “Medications." Then select "Convert Retail Prescriptions" in the left-hand navigation column and follow the instructions to convert online. A trained MCC Patient Care Advocate will walk you through the process and convert your medication(s) to home delivery. Once you are registered. from the left-hand navigation bar. instead of brand-name medications. which means that the Department of Defense (DoD) will only pay for a specified amount (a 30-. you can use the mail-order pharmacy if the medication is not covered under the other plan or if you exceed the dollar limit of coverage under the other plan. the Northern Mariana Islands.” Then.3.mil/pharmacy.tricare. American Samoa. If you insist on having a prescription filled with a brand-name drug that is not considered medically necessary. Quantity limits are applied to ensure the medications are safely and appropriately used.tricare. COVERED SERVICES. you can call toll-free 1-866-DoD-TRRX (1-866-363-8779) or 1-866-DoD-TMOP (1-866-363-8667). AZ 85072-9954 Include the written prescription and the appropriate copayment when you mail your registration. select “Prior Authorization. Your medications will be sent directly to your home within approximately 14 days after your prescription is received. You can convert maintenance prescriptions (prescriptions you take on a regular basis) that you have filled at a TRICARE Retail Network Pharmacy to the TRICARE Mail Order Pharmacy via the Member Choice Center (MCC). the brandname drug will be dispensed at the brand-name copayment. Some drugs require prior authorization. Download the registration form at www. go to www.tricare. Box 52150 Phoenix.

Newborns are covered separately.com or call toll-free 1-800-866-8499 for general information.tricare. You may be able to have nonformulary prescriptions filled at the formulary costs if your provider can establish medical necessity. Inc. Maternity Services Prenatal care is important. TRICARE will not cover any remaining maternity costs unless your family qualifies for other TRICARE health coverage or has enrolled in the Continued Health Care Benefit Program. Maternity Ultrasounds TRICARE covers maternity ultrasounds when medically necessary. If you are overseas. TRS covers maternity care.TRICAREdentalprogram. to check for generic equivalents. seek appropriate medical care. Refer to your regional contractor’s Web site for additional details on maternity ultrasound coverage.org. To enroll. call 1-888-622-2256. visit www. and we strongly recommend that those who are pregnant. Note: Non-formulary drugs are generally not available at MTFs. including prenatal care. visit the online TRICARE Formulary Search Tool at www. delivery. or call 1-877-DoD-MEDS (1-877-363-6337) and select option seven for pharmacy details. If your TRS coverage ends during your pregnancy.tricareformularysearch. Medically necessary hospital and professional services (prenatal and postnatal) are covered. TRICARE does not cover routine ultrasound screening.. and postpartum care. Only maternity ultrasounds with a valid medical indication that constitutes medical necessity are covered by TRICARE. . Some providers may offer patients routine ultrasound screening as part of the scope of care after 16–20 weeks of gestation. in addition to any other services deemed medically necessary. visit the United Concordia Companies. Non-formulary drugs are available to beneficiaries from the mail-order or retail pharmacies at a higher cost. refer to “Coverage for Newborns or Adopted Children” in the Changes to Your TRICARE Reserve Select Coverage section of this handbook. For procedures on how to add your newborn to your TRS coverage. For information on how to save money and make the most of your pharmacy benefit.Non-Formulary Drugs Any drug determined to be not as clinically effective or not as cost-effective as other drugs in its therapeutic class may be recommended for placement in the “non-formulary” classification. See “When TRICARE Reserve Select Coverage Ends” in the Changes to Your TRICARE Reserve Select Coverage section of this handbook. Some situations that are covered include: • Estimating gestational age • Evaluating fetal growth • Conducting a biophysical evaluation for fetal well-being • Evaluating a suspected ectopic pregnancy • Defining the cause of vaginal bleeding 16 Dental Services The TRICARE Dental Program (TDP) is separate from other TRICARE programs and is not contingent upon enrollment in TRS. To learn more about medications and common drug interactions. Web site at www. call toll-free at 1-888-418-0466 or 1-717-975-5017.mil/pharmacy. • Diagnosing or evaluating multiple gestations • Confirming cardiac activity • Evaluating maternal pelvic masses or uterine abnormalities • Evaluating suspected hydatidiform mole • Evaluating the fetus’s condition in late registrants for prenatal care A physician is not obligated to perform ultrasonography on a patient who is low risk and has no medical indications constituting medical necessity. or to determine if a drug is classified as a non-formulary medication. and those who anticipate becoming pregnant. For more information about the TDP.

Contact lenses and/or eyeglasses are covered only for: • Treatment of infantile glaucoma • Corneal or scleral lenses for treatment of keratoconus • Scleral lenses to retain moisture when normal tearing is not present or is inadequate • Corneal or scleral lenses to reduce corneal irregularities other than astigmatism • Intraocular lenses. cleaning. The attending physician must certify in writing that the abortion was performed because a life-threatening condition existed. when used for reasons of personal convenience. The provider’s “Certificate of Recognition” from the ADA must accompany the claim for reimbursement. This documentation is also required for premature infants delivered in non-hospital settings. Hospital-grade electric breast pumps may also be covered after the premature infant is discharged from the hospital with a physiciandocumented medical reason. LIMITATIONS & EXCLUSIONS SECTION 2 Breast Pumps Cardiac and Pulmonary Rehabilitation Chiropractic Care Cosmetic.Services or Procedures with Significant Limitations Figure 2. hospital-grade electric breast pumps (including services and supplies related to the use of the pump) for mothers of premature infants are covered. ocular injury. Check your regional contractor's Web site for additional information. are excluded even if prescribed by a physician. Figure 2. This list is not intended to be all-inclusive. or after a medically necessary mastectomy. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded. surgical. This program is not available under TRS. or congenital absence Note: Adjustments.. Medical documentation must be provided. An electric breast pump is covered while the premature infant remains hospitalized during the immediate postpartum period. MTFs may not be able to provide such services based upon limited capabilities. and repairs for eyeglasses are not covered. restore body form after a serious injury.e. improve appearance of a severe disfigurement. dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition). Only covered when used to restore function. Coverage is limited to ADSMs and is only available at specific MTFs under the Chiropractic Care Program. Breast pumps of any type. Both are covered only for adjunctive dental care (i. contact lenses. Heavy-duty. Plastic. Outpatient diabetic self-management and training programs are covered when the services are provided by a TRICARE-authorized individual provider who also meets national standards for diabetes self-management education programs recognized by the American Diabetes Association® (ADA). Both are covered only for certain indications.5 COVERED SERVICES. and behavioral health care services that may not be covered unless exceptional circumstances exist.5 is a list of medical. Services or Procedures with Significant Limitations Service Abortions Description Abortions are only covered when the life of the mother would be endangered if the pregnancy were carried to term. or Reconstructive Surgery Cranial Orthotic Device or Molding Helmet Dental Care and Dental X-Rays Education and Training Eyeglasses or Contact Lenses 17 . Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. or eyeglasses for loss of human lens function resulting from intraocular surgery. correct a serious birth defect.

or Vitamins Gastric Bypass Description Covered when used as the primary source of nutrition for enteral. or oral nutritional therapy. gastric stapling. Shoe Inserts. parenteral. gamete intrafallopian transfer. Orthopedic shoes may be covered when a permanent part of a brace. Routine genetic testing is not covered. Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment system may provide the patient with a private room. This list is not intended to be all-inclusive. For individuals with diabetes. Laser/LASIK/Refractive Covered only to relieve astigmatism following a corneal transplant. The following specific services are excluded under any circumstance. The patient has had an intestinal bypass or other surgery for obesity and. extra-depth shoes with inserts or custom-molded shoes with inserts may be covered. Food Substitutes or Supplements. TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including behavioral health disorders) or injury. Shoe Modifications. cholecystitis. and when the results of the test will influence the medical management of the patient.. vocational counseling. Pickwickian syndrome (and other severe respiratory diseases). or for the diagnosis and treatment of pregnancy or well-baby care. An associated medical condition is not required for this category. The patient is 200 percent or more of the ideal weight for height and bone structure. hypertension. educational counseling. or physical disabilities and for patients age 5 or under. For example. Intraperitoneal nutrition (IPN) therapy is covered for malnutrition as a result of end-stage renal disease. or gastroplasty—to include vertical banded gastroplasty—is covered when one of the following conditions is met: 1. Shoes. mental. Exclusions In general. but will only receive the standard DRG amount. or life-style modification. Corneal Surgery Private Hospital Rooms Not covered unless ordered for medical reasons or a semiprivate room is not available. and counseling for socioeconomic purposes.g. Check your regional contractor’s Web site for additional information. 3. . General Anesthesia Services and Institutional Costs for Non-Adjunctive Dental Treatment Genetic Testing Covered when medically necessary to safeguard a patient’s life or in conjunction with non-adjunctive dental treatment (dental care not related to a medical condition) for patients with developmental. including in-vitro fertilization. because of complications. stress management. The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus. or provided by an unauthorized provider. weight loss) • Care or supplies furnished or prescribed by an immediate family member • Charges that providers may apply to missed or rescheduled appointments • Counseling services that are not medically necessary in the treatment of a diagnosed medical condition. All services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment. Gastric bypass. Covered when medically proven and appropriate. and Arch Supports Shoe and shoe inserts are covered only in very limited circumstances. or severe arthritis of the weight-bearing joints. requires a second surgery (a takedown). The hospital may bill the patient for the extra charges if the patient requests a private room. hypothalamic disorders. narcolepsy. and all other such reproductive technologies • Autopsy services or postmortem examinations • Birth control/contraceptives (non-prescription) • Bone marrow transplants for treatment of ovarian cancer • Camps (e. 2. are excluded.Services or Procedures with Significant Limitations (continued) Service Food. • Acupuncture • Alterations to living spaces 18 • Artificial insemination.

health club memberships. immunizations.g. except as previously outlined in “Services or Procedures with Significant Limitations. weight loss counseling.” earlier in this section. whirlpools. whether or not admission is to an authorized institution • To perform diagnostic tests. such as severe diabetes • General exercise programs. radio. wiring of the jaw. grant. • Smoking cessation services and supplies • Sterilization reversal surgery • Surgery performed primarily for psychological reasons (such as psychogenic) 19 . except if benefits provided under these laws are exhausted • That are (or are eligible to be) fully payable under another medical insurance or program. even if recommended by a physician and regardless of whether rendered by an authorized provider • Inpatient stays: • For rest or rest cures • To control or detain a runaway child. or research program • Furnished or prescribed by an immediate family member COVERED SERVICES. or continued inpatient stay of a newborn infant primarily for purposes of remaining with the mother when the mother (but not the newborn infant) requires extended postpartum inpatient stay • Preventive care. either private or governmental. or other such charges or items • Experimental or unproven procedures • Foot care (routine) except if required as a result of a diagnosed systemic medical disease affecting the lower limbs. such as beauty and barber services. TRICARE is the secondary payer for any remaining charges.) • Sex changes or sexual inadequacy treatment. such as routine annual or employment-requested physical examinations.) • Psychiatric treatment for sexual dysfunction • Services and supplies: • Provided under a scientific or medical study. However. swimming pools. and telephone • Postpartum inpatient stay of a mother for purposes of staying with the newborn infant (usually primarily for the purpose of breastfeeding the infant) when the infant (but not the mother) requires the extended stay. hot tubs. whether such benefits have been applied for or paid. such as coverage through employment or Medicare (In such instances. Diets. television. weight loss medications. LIMITATIONS & EXCLUSIONS SECTION 2 • For which the beneficiary has no legal obligation to pay or for which no charge would be made if the beneficiary or sponsor were not eligible under TRICARE • Furnished without charge (e. directed or agreed to by a court or other governmental agency (unless medically necessary) • Required as a result of occupational disease or injury for which any benefits are payable under a worker’s compensation or similar law.. treatment of ambiguous genitalia which has been documented to be present at birth is covered. routine screening procedures. examinations. except as provided in the Clinical Preventive Services list (See “Clinical Preventive Services” earlier in this section. spas. and procedures that could have been and are performed routinely on an outpatient basis • In hospitals or other authorized institutions above the appropriate level required to provide necessary medical care • Learning disability services • Megavitamins and orthomolecular psychiatric therapy • Mind expansion and elective psychotherapy • Naturopaths • Non-surgical treatment of obesity or morbid obesity • Personal. or convenience items. or similar procedures are excluded • Inpatient stays. comfort.• Custodial care • Diagnostic admissions • Domiciliary care • Dyslexia treatment • Electrolysis • Elevators or chair lifts • Exercise equipment. cannot file claims for services provided free-of-charge) • For the treatment of obesity.

even if prescribed by a physician. except for cancer-screening mammography. laboratory. and other tests allowed under the clinical preventive services benefit. cancer screening. Pap tests. to obtain medical care • X-ray. and pathological services and machine diagnostic tests not related to a specific illness or injury or a definitive set of symptoms. except when such absences are specifically included in a treatment plan approved by TRICARE • Transportation except by ambulance • Travel.• Therapeutic absences from an inpatient facility. 20 .

You can download forms and instructions from the TRICARE Web site at www. TRICARE does not reimburse you for this charge. not where you received care. participating provider. making sure it contains the following: • Social Security number of the sponsor (the National Guard or Reserve member) • Beneficiary (patient) name • Provider’s name and address (If more than one provider’s name is on the bill. or deductibles. If you see a non-network. TRICARE will reimburse you directly for the TRICARE-allowable charge minus any applicable deductible and cost-share. TRICARE-authorized provider who chooses not to participate on the claim.1 in the Getting Care section of this handbook. they will not be paid for services rendered. that provider must be an authorized TRICARE provider. Note: You should ask any non-network provider if they are participating and authorized by TRICARE. You may be required to pay up front for services if you see a non-network. If providers are not participating. your provider will submit claims on your behalf.Claims Health Care Claims In order for TRICARE to pay any provider. and you will have to pay the charge out of pocket. You will be reimbursed for TRICAREcovered services at the TRICARE-allowable charge. As noted in Figure 1. Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. file TRICARE claims based on where you live. If you see a TRICARE network provider or a non-network. If you have claims questions. circle the name of the person who treated you. If providers are not authorized by TRICARE. call your regional contractor. you may be required to submit your own health care claims. less any copayments. cost-shares. obtain and fill out a Patient’s Request for Medical Payment (DD Form 2642). All network providers are both TRICAREauthorized providers and participating TRICARE providers. Note: Providers submit inpatient facility claims. attach a readable copy of the provider’s bill to the claim form. you may incur charges up to 15 percent above the TRICAREallowable charge for covered services. the regional contractor can assist them. non-participating provider.) Be sure to complete all 12 blocks of the form correctly and sign it. To file a claim. be sure to complete block 8a on the form.mil/claims or from your regional contractor’s Web site. You also can get forms and instructions at a TRICARE Service Center (TSC) or a military treatment facility (MTF). if the provider is also participating. If a provider would like to become a TRICARE-authorized provider. LIMITATIONS & EXCLUSIONS SECTION 2 • Date and place of each service • Description of each service or supply furnished • Charge for each service • Diagnosis (If the diagnosis is not on the bill. Claims should be submitted to the claims processor in the region where you live. Remember that nonparticipating providers can charge you up to 15 percent above the TRICAREallowable charge for services in addition to your cost-share and/or deductible. the provider will file claims for you. When filing a claim.) COVERED SERVICES. If you receive care while traveling. In this case. CLAIMS SECTION 3 21 .tricare.

O.triwest. To file a claim.com www. Wisconsin Physicians Service (WPS) has been subcontracted by Humana Military to provide claims processing services for all overseas TRICARE areas. if available • Prescription number of each drug • Name and address of the pharmacy • Name and address of the prescribing physician TRICARE Reserve Select (TRS) claims for services received overseas are processed under the TRICARE South Region contract. Using a Continental United States (CONUS) address will result in payment problems. Box 870140 Surfside Beach. Keep a copy of your paperwork for your records. call your regional contractor.myTRICARE.humana-military.tricare.mil/claims.tricare.tricare. you must meet an annual TRICARE deductible. and price of each drug • National Drug Code (NDC). LLC c/o PGBA. 22 .com TRICARE West Region Send claims to: West Region Claims P. Call 1-866-DoD-TRRX (1-866-363-8779) with questions about filing a pharmacy claim. Prescription claims require the following information for each drug: • Name of the patient • Name.O. quantity dispensed.com.healthnetfederalservices. Click on “TRICARE Claim Form (DD Form 2642)” under “Downloads” in the right-hand navigation column.1.com TRICARE South Region Send claims to: TRICARE South Region Claims Department P.1 Send claims to the address listed for your region in Figure 3. When you fill out patient information and claim forms. LLC/TRICARE P. Box 7031 Camden. be sure to use your overseas APO or FPO mailing address and attach photocopies of fully itemized bills from the provider showing the cost for each service or supply provided. (See “Coordinating Benefits with Other Coverage” later in this section. SC 29587-9740 www. obtain and fill out a Patient’s Request for Medical Payment (DD Form 2642). obtain and fill out a Patient’s Request for Medical Payment (DD Form 2642). strength. visit www. To file a pharmacy claim. or visit the TRICARE Web site at www.myTRICARE.Regional Claims Processing Information TRICARE North Region Send claims to: Health Net Federal Services.TRICARE4u.com www. For claims processing information. days’ supply.mil/claims or from your local TSC and a TRICARE Point of Contact (POC). SC 29020-7031 www. Overseas Claims Pharmacy Claims You may have to submit your own pharmacy claims if you fill prescriptions at a non-network pharmacy or if you have other health insurance (OHI). Claims must be filed within one year of the date of service. date filled.O. WI 53707-1028 www. Box 77028 Madison. You can download forms and instructions at www.TRICARE4u. You can download forms at www.mil/claims.) Before reimbursement is granted for non-network pharmacy claims. visit your regional contractor’s Web site.com Figure 3. Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. For information and assistance in filing claims for services received overseas.com www.

Otherwise.O.2 Send claims to the address listed for your overseas region in Figure 3.2. To locate a POC near you. How TRICARE Calculates Payment with OHI TRICARE regulations require coordination of benefits with OHI coverage. Other Health Insurance TRS is the secondary payer after all health benefits and insurance plans. except for Medicaid. WI 53707-7985 TRICARE Pacific WPS—Overseas Claims P. Box 7985 Madison. TRICARE may also deny your claim. This ensures timely overseas claims filing and payment. You will be directed to a nearby MTF or to a TRICARE-authorized provider for care. However. Therefore. Payment calculations differ by provider status as follows. TRS deductibles and cost-shares do not apply to care for line-of-duty conditions.O.O. and other programs or plans as identified by the TRICARE Management Activity. WI 53708-8976 TRICARE Latin America and Canada WPS—Overseas Claims P. Due to these regulations. and the provider may not bill you. It is important to follow the requirements of your OHI. TRICARE pays the lesser of: • The allowed amount minus the OHI payment Coordinating Benefits with Other Coverage Line-of-Duty Care TRICARE Reserve Select (TRS) does not cover care associated with a line-of-duty injury. you can file the claim with TRICARE for reimbursement. National Guard and Reserve members who have a line-of-duty condition must have the appropriate paperwork to receive care under lineof-duty procedures. 23 CLAIMS SECTION 3 • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copayment/deductible) . For more information about obtaining line-of-duty care. contact the TRICARE Area Office or an overseas dental treatment facility in your area. Any necessary care for lineof-duty conditions must be coordinated through your unit or Reserve Center. contact your unit or Reserve Center. WI 53707-7985 Figure 3. or disease. then no TRICARE payment is authorized. TRICARE supplements. and continued beneficiary access to quality host-nation health care. The charge is considered paid in full. If there is an amount your OHI does not cover. Keep a copy of your paperwork for your records. TRICARE Point of Contact Program The TRICARE Overseas Program (TOP) POC Program is a liaison service that assists beneficiaries and host-nation providers in remote locations in filing medical and TRICARE Dental Program claims. If your OHI denies a claim for failure to follow their rules. Box 7985 Madison. illness. Line-of-duty conditions are covered 100 percent by the Department of Defense under line-of-duty procedures separate from TRS. TRICARE does not always pay the OHI copayment or the balance remaining after the OHI pays. Keep your regional contractor and health care providers informed about your OHI so that they can coordinate your benefits and help ensure that there is no delay or denial in the payment of your claims. you’ll need to follow the OHI’s rules for filing claims and file the claim with them first. If you have other health insurance (OHI). such as obtaining care without authorization or using a non-network provider. Box 8976 Madison.Overseas Claims Addresses TRICARE Europe WPS—Overseas Claims P. TRICARE Network Individual/Group Providers and Most Inpatient Facilities If your OHI pays more than the TRICAREallowed amount. the Indian Health Service. your liability is usually eliminated.

) You should keep EOBs with your health insurance records for reference. TRICARE pays the lesser of: • 115 percent of the allowed amount minus the OHI payment • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copayment/deductible) Staff Model HMOs. 24 . and Other Capitated OHI Plan Providers If you are enrolled in one of these OHI plans. The Statement of Personal Injury Third Party Liability (DD Form 2527) form will be sent to you if a claim appears to have third-party liability involvement. Pharmacy Claims When using OHI. Third-Party Liability The Federal Medical Care Recovery Act allows TRICARE to be reimbursed for its costs of treatment if you are injured in an accident that was caused by someone else. It is an itemized statement that shows what action TRICARE has taken on your claims. then no TRICARE payment is authorized. Explanation of Benefits An EOB is not a bill. For processing. unless the medication is not covered under the other plan. After reviewing the EOB. You may not use TRICARE’s mail-order pharmacy if you have OHI prescription drug coverage. (For more information about appeals. and you may only receive partial reimbursement of your HMO copayment. Group HMOs. You can download the DD Form 2527 at www. you can submit a Patient’s Request for Medical Payment (DD Form 2642) with a copy of your HMO copayment receipt. An EOB is for your information and files. Deductibles and cost-shares are applied. the charge is considered paid in full.tricare. Otherwise. When you have OHI. and an itemized bill or explanation of benefits (EOB) may not be available.mil/claims or from your regional contractor’s Web site. If your OHI paid more than 115 percent of the TRICARE-allowable charge. or unless you exceed the dollar limit of coverage under the other plan. Within 35 calendar days you must complete and sign this form and follow the directions for returning it to the appropriate claims processor. and the provider may not bill you. the OHI is the first payer for pharmacy coverage. the provider/group either works directly for the HMO or is paid a monthly or annual amount rather than a fee for each service performed. In these plans you may only receive a copayment receipt. you have the right to appeal certain decisions regarding your claims and must do so in writing within 90 days of the date of the EOB notice. In these cases. including copayments. the copayment is considered the billed amount.Non-Network Individual/Group Providers Who Accept TRICARE Assignment (Participating) TRICARE pays the lesser of: • The billed amount minus the OHI payment • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copayment/deductible) Non-Network Individual/Group Providers Who Do Not Accept TRICARE Assignment (Nonparticipating) Nonparticipating providers may only bill you up to 15 percent above the TRICARE-allowable charge. you should use a retail pharmacy under your private insurer that is also in the TRICARE retail pharmacy network to avoid paying the TRICARE non-network deductible. You should call 1-866-DoD-TRRX (1-866-363-8779) for specific instructions about filing pharmacy claims if you have OHI. If you have OHI. the rules of that insurer apply. You may then be eligible for full or partial reimbursement from TRICARE for out-of-pocket costs. see the Information and Assistance section of this handbook.

3 CLAIMS SECTION 3 25 .For a sample of the EOB in your region along with instructions for reading the EOB.1 • South Region: Figure 8.2 • West Region: Figure 8. see the following figures in the Appendix section of this handbook: • North Region: Figure 8.

If the TRS Request form is not received by the TSC or 26 .osd. the child must be enrolled for claims to be paid. Adding a Newborn or Adopted Child When You Have Member-Only Coverage With TRS member-only coverage. a change from memberonly to member-and-family coverage). Note: Since a family plan already exists. Print the TRS Request form from the TRS Web application.Changes to Your TRICARE Reserve Select Coverage Changes to Your Coverage When you experience a change in your family composition certain actions are necessary to ensure continuous TRICARE Reserve Select (TRS) coverage for all eligible family members. first.jsp and follow the prompts for making changes to family composition. the effective date of the premium change will be the date the family change occurred. If the member wants coverage retroactive to the date of the birth or adoption. and send it to your TRICARE regional contractor. you must log on to the TRS Web application at https://www. sign it. additional premiums will not be required when enrolling the new child. Adding a Newborn or Adopted Child to Existing Member-and-Family Coverage With TRS member-and-family coverage. When a change is processed that alters the premium amount (e.mil/appj/trs/index. If the TRS Request form is not received by the TSC or the regional contractor or postmarked within 60 days. The effective date of coverage is the date the family change occurred. Coverage for Newborns or Adopted Children TRS coverage for newborns or adopted children differs depending on the type of coverage the sponsor (the National Guard or Reserve Member) has: TRS member-and-family or TRS member-only. Children can continue TRS with no break in coverage if the TRS Request form is postmarked or received by the TRICARE Service Center (TSC) or the regional contractor within 60 days of the birth or adoption. you must report the change in family composition as described in “Updating DEERS” in the Information and Assistance section of this handbook. Examples of changes in family composition include: • Marriage • Birth or adoption of child • Placement of a child in the legal custody of the National Guard or Reserve member by an order of the court • Divorce or annulment • Death of a spouse or family member • Last family member becomes ineligible (requires a change from TRS member-andfamily to TRS member-only coverage) To ensure there is no interruption to your TRS coverage. Beyond 60 days. newborns or adopted children are not automatically covered and claims will not be paid until the newborn or adopted child is registered in DEERS and a TRS Request form is received.g.. and the member is responsible to pay the total amount for all health care the child received. any further TRS coverage for the child is terminated. the request for member-and-family coverage must be received by the TSC or the regional contractor or postmarked within 60 days of the birth or adoption. Second. newborns and adopted children are covered automatically by TRS for 60 days after the birth or adoption. All pended claims will be denied.dmdc. This form must be postmarked or received by your regional contractor no later than 60 days from the date of the family change.

If you become eligible for other TRICARE coverage for a period of 30 days or less. as well as any TRS enrolled family members. • Complete the TRS Request form. if you become eligible for one of the programs listed below. then you as the sponsor. If you want to enroll for TRS coverage at that time. you must follow the procedures to qualify for and purchase TRS coverage again. Other TRICARE coverage may include coverage before (early eligibility). A one year TRS purchase lockout will apply to members who voluntarily terminate TRS coverage. • Sponsor or family member becomes eligible for. do not just stop making payments. become eligible for other TRICARE coverage through a family member. you are still responsible for any premium amounts that were CHANGES TO YOUR TRS COVERAGE SECTION 4 . You must take the following action to end your TRS coverage: • Log on to the Guard and Reserve Web Portal at https://www. TRS coverage will terminate. However. your coverage terminates. Voluntary Termination When TRICARE Reserve Select Coverage Ends TRS coverage may be terminated for a number of reasons. the Federal Employees Health Benefits program • Sponsor leaves the Selected Reserve • Divorce • Child reaches age 21 (or 23 if enrolled as a full time student in college) Eligibility for Other TRICARE Coverage You may become eligible for other TRICARE coverage at any time. If you want to terminate coverage. Management Program or TAMP) periods of activation. Any premium amounts already paid for periods beyond the termination date will be refunded as described previously. • CHAMPVA • Another federally sponsored health benefits program. Note: This list is not all inclusive. or covered under. It is important to note that TRS coverage will not automatically resume after other TRICARE coverage ends. and the member is responsible to pay the total amount for all health care the child received. The sponsor is responsible for paying the increase in premium. If you. Loss of Eligibility Sponsors or family members may lose eligibility for TRS coverage for the following reasons. and after (Transitional Assistance 27 You may request to terminate TRS coverage at any time. there is an increase in the monthly premium. When TRS coverage is terminated. Note: When the type of plan changes from member only to member and family. may terminate TRS coverage without incurring a lockout. sign.the regional contractor or postmarked within 60 days. and mail your completed TRS Request form to your regional contractor. your TRS coverage will be terminated. such as the Federal Employees Health Benefits program. which begins on the date of the birth or adoption. A purchase lockout means you will not be able to purchase TRS coverage for one year from the effective date of termination.mil/appj/trs/index.dmdc. your family members’ coverage automatically ends as well. during (active duty coverage).jsp. all pended claims will be denied. the National Guard or Reserve member. If you do not take action to terminate coverage and you simply stop making premium payments. Additionally.osd. When your TRS coverage is terminated for any reason. the same as any beneficiary purchasing new coverage. • Print. the regional contractors will initiate your premium payment refund process within 10 days of receiving a written TRS termination request. TRS coverage will continue unchanged. If you become eligible for other TRICARE coverage for a period of more than 30 consecutive days.

28 .) Termination of coverage due to nonpayment will result in a TRS purchase lockout for one year or until overdue premiums are paid in full. at 1-800-444-5445 or visit www.osd. CA 93955-6771 The request must include: • Sponsor’s name and Social Security number • Name of person for whom the certificate is requested • Reason for the request • Name and address to whom and where the certificate should be sent • Requester’s signature You cannot request a certificate by phone. Humana Military. Failure to pay monthly premiums on time will result in termination of coverage. Continued Health Care Benefit Program Once your eligibility under TRS ends. (This may result in up to two months or more of overdue premium payments. If there is an urgent need for a certificate of creditable coverage.com. For more information.due prior to the date you were officially terminated from TRS. Termination Due to Non-Payment Your payment is due no later than the last day of each month. Benefits under CHCBP are virtually the same as those under TRS. and the certificate issue date. TRICARE. contact the DSO at 1-800-538-9552. Each certificate identifies the name of the sponsor or family member for whom it is issued. Certificates reflect the most recent period of continuous coverage under TRICARE. Certificate of Creditable Coverage When your TRS coverage ends. whichever is longer.mil or visit www. For TTY/TDD. fax your request to the DSO at 1-831-655-8317 and/or request that the DSO fax the certificate to a particular number. The Defense Manpower Data Center Support Office (DSO) will issue a certificate of creditable coverage to sponsors and family members upon loss of eligibility. transitional medical coverage under the Continued Health Care Benefit Program (CHCBP).tricare. If you qualify.humana-military. you will receive a certificate of creditable coverage. but not part of. Note: The government pursues collection action for overdue and delinquent premiums and may notify your commander and collect these amounts from your National Guard or Reserve pay. the dates TRICARE coverage began and ended. To find out if you are eligible for CHCBP. but you must still pay any overdue amounts. Send your written requests for a certificate of creditable coverage to the DSO at: Defense Manpower Data Center Support Office Attn: Certificate of Creditable Coverage 400 Gigling Road Seaside. Certificates issued upon request of a beneficiary reflect each period of continuous coverage under TRICARE that ended within the 24 months prior to the date of loss of eligibility. The certificate of creditable coverage is a document that serves as evidence of prior health care coverage under TRICARE so that you cannot be excluded from a new health plan for pre-existing conditions. CHCBP is a premium-based health care program and is similar to.mil/certificate. Your payment will apply to the following month of coverage. contact the program administrator. dial 1-866-363-2883. You may send questions via e-mail to the TRICARE Management Activity Office of HIPAA Electronic Standards at hipaamail@tma. you may be able to apply for temporary. you must enroll yourself and your eligible family members in CHCBP within 30 days after termination of TRS coverage.

• If TRS member-only coverage is in effect on the date of the member’s death. TRICARE Reserve Select Survivor Coverage If a National Guard or Reserve member is covered by TRS on the day of his or her death. The effective date of coverage is the day after the date of death. Surviving family members will receive letters advising them of their coverage and their option to terminate. Eligible family members may purchase TRS survivor coverage within 60 days after the date of death by submitting a TRS Request form. DEERS will automatically convert your TRS member-and-family coverage to TRS survivor coverage. DEERS will also establish an end date for eligibility six months from the date of the member’s death. Surviving family members are responsible for paying applicable monthly premiums. CHANGES TO YOUR TRS COVERAGE SECTION 4 29 . Two scenarios apply depending on the type of coverage in effect at the time of the member’s death. the coverage will terminate effective on the date of death. surviving family members may purchase or continue coverage for an additional six months beyond the date of the member’s death. as well as instructions for accessing the TRS Request form. The request must be received by the TSC or regional contractor or postmarked no later than 60 days after the date of the member’s death. if desired. • If TRS member-and-family coverage is in effect on the date of the member’s death. Surviving family members will receive letters advising them of their option to purchase coverage.

and deployed.dmdc.Information and Assistance Qualifying for TRICARE Reserve Select For information or assistance with qualifying for and purchasing TRICARE Reserve Select (TRS). a TRICARE Service Center. (DD Form 1172) and provide other important documentation such as marriage. You can find the closest facility at www. health care claims. DEERS can be updated using one of the following methods: • Visit a local uniformed services ID card-issuing facility. visit www. the sponsor must have the DD Form 1172 notarized.dmdc.tricare. or TRICARE Area Office if overseas. area serves all overseas areas. Medicare cards. and can advise you about obtaining health care.m.osd.mil/rsl/owa/home. Locate one at www. To locate a BCAC near you. family members’ Social Security numbers.C. You or a family member should contact the nearest uniformed services identification (ID) card-issuing facility to find out what documents you need in order to register or update eligibility information in DEERS. If family members reside at a different address. for information or assistance with purchasing TRS coverage.mil. visit the TRICARE Web site at www. A National Guard and Reserve BCAC located in the Washington.osd. Beneficiary Counseling and Assistance Coordinators Beneficiary counseling and assistance coordinators (BCACs) can help you with TRICARE and Military Health System inquiries and concerns. contact your Service personnel office. except Federal holidays) • Fax changes to DEERS at 1-831-655-8317. You can verify DEERS information by contacting your regional contractor’s toll-free number.mil/bcacdcao for an online directory. Updating DEERS To register family members or to update their records. (Monday–Thursday from 6 a.osd.mil/appj/trs/index.defenselink. etc. you must complete the Application for Department of Defense Common Access Card and DEERS Enrollment. you can explore the plan you are using and see how the benefits change when you are activated. CA 93955-6771 30 Customer Service Contact your regional contractor.mil For more information about your TRICARE benefits and how they change during periods of activation and deactivation. Refer to pages 2–3 of this handbook for a list of regional contractor telephone numbers and Web addresses. or covered benefits. You must update each family member’s eligibility record separately when changes occur. Pacific Time. to 3:30 p. DD 214s (separation papers from active duty). BCACs are located at military treatment facilities (MTFs) and at the TRICARE Regional Offices (TROs). Each of the three TROs has a special National Guard and Reserve BCAC available to assist you with specific TRICARE questions or concerns you may have as a National Guard or Reserve member or family member.dmdc. • Call the Defense Manpower Data Center Support Office at 1-800-538-9552. or a BCAC at your local MTF. birth or death certificates.tricare.mil/ra • Guard and Reserve Web Portal: https://www. • Reserve Affairs Web site: www.m. D. deactivated. www.tricare.mil/rsl/owa/home. obtaining health care services. Once you have . • Mail changes to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside.jsp entered your profile. premium billing and payment collection.

For specific information about filing an appeal in your region.1 An appropriate appealing party must submit the appeal. even though no care has been provided and no claim submitted. Filing an Appeal Appeals must be filed with your regional contractor within specific deadlines. A non-expedited review of a denial must be filed no later than 90 days after receipt of the initial denial. it will not be processed.1. For example. Proper appealing parties include: • You.2 on the following page for submitting different types of appeals. The notification will include an explanation of what was denied or why a payment was reduced and the reasoning behind that decision. See the addresses in Figure 5. the beneficiary • Your custodial parent (if you are a minor) or your guardian • A person appointed in writing by you to represent you for the purpose of the appeal 1 • An attorney filing on your behalf • Non-network participating providers If a physician or other party is going to submit the appeal. Prior-authorization-denial appeals may either be expedited or non-expedited. which is available on your regional contractor’s Web site. For example.INFORMATION AND ASSISTANCE SECTION 5 Appealing a Decision If you believe a service or claim was improperly denied. An appeal must involve an appealable issue. There must be an amount in dispute to file an appeal. 2 3 4 5 The appeal must be in writing. The following are non-appealable issues: • Allowable charges • Eligibility • Denial of nonavailability statements (NAS) for inpatient behavioral health care • Denial of services from an unauthorized provider • Denial of treatment plan when an alternative treatment plan is selected The appeal must be filed in a timely manner. An appeal must be filed within 90 days after the date on the EOB or denial notification letter. When services are denied based on a medical necessity or a benefit decision. 31 . you (or another appropriate party) may file an appeal. TRICARE Appeal Requirements Appeal Requirements Your appeal must meet the requirements listed in Figure 5. You also may appeal the denial of a requested authorization of services. Figure 5. in whole or in part. There are some things you may not appeal. contact your regional contractor. If you are not satisfied with a decision rendered on an appeal. you must complete and sign an Appointment of Representative and Authorization to Disclose Information form. The issue in dispute must be an appealable issue. You or an appointed representative must file an expedited appeal within three calendar days after receipt of the initial denial. In an appeal case involving denial of an authorization in advance of receiving the actual services. depending on the urgency of the situation. you have the right to appeal TRICARE decisions regarding the payment of your claims. the amount in dispute is deemed to be the estimated TRICARE-allowable charge for the services requested. there are further levels of appeal. Note: Network providers are not appropriate appealing parties (unless appointed by you in writing). If the appeal is submitted without this form. you may not appeal the denial of services from an unauthorized provider. There is no minimum disputed amount necessary to request reconsideration. you are notified automatically in writing.

Box 870142 Surfside Beach. military providers. address. or subcontractor personnel—to provide appropriate and timely health care services. FL 32255-1138 TRICARE West Region Claims Appeals: Figure 5.2 TriWest Healthcare Alliance Corp. Box 202002 Florence. LLC c/o PGBA LLC/TRICARE Claims Appeals P. a TRICARE contractor. Box 740044 Louisville.O.Appeals should contain the following information: • Beneficiary’s name. or to deliver the proper level of care or service. AZ 85080 Prior Authorization Appeals: TriWest Healthcare Alliance Corp.O. LLC/TRICARE Authorization Appeals P. Claims Appeals P.O. Inc.O. KY 40201-9973 Behavioral Health Appeals: ValueOptions Behavioral Health Attn: Appeals and Reconsideration Department P. Grievances are resolved no later than 60 days from receipt. or other representative of an eligible dependent child may file a grievance. sponsor. Claims Appeals P. AZ 85080 32 . See Figure 5.O.2 for details. SC 29502-2002 Prior Authorization Appeals: Humana Military Healthcare Services. The grievance process allows full opportunity to report in writing any concern or complaint regarding health care quality or service. LLC c/o PGBA. Attn: Clinical Appeals P. Following resolution. TRICARE beneficiary. Box 86508 Phoenix. Regional Appeals Filing Information TRICARE North Region Claims Appeals: Health Net Federal Services. or quality. Filing a Grievance A grievance is a written complaint or concern dealing with a non-appealable issue regarding a perceived failure by any member of the health care delivery team—including TRICAREauthorized providers. access. Any TRICARE civilian or military provider. Box 551138 Jacksonville. Your regional contractor is responsible for the investigation and resolution of all grievances. Box 870148 Surfside Beach.O. and telephone number • Sponsor’s Social Security number (SSN) • Beneficiary’s date of birth • Beneficiary’s or appealing party’s signature A description of the issue or concern must include: • The specific issue in dispute • A copy of the previous denial determination notice • Any appropriate supporting documents Send your appeal to your regional contractor. SC 29587-9748 Claims Appeals Fax: 1-888-458-2554 Prior Authorization Appeals: Health Net Federal Services. SC 29587-9742 Prior Authorization Appeals Fax: 1-888-881-3622 TRICARE South Region Claims Appeals: TRICARE South Region Appeals P. Box 86508 Phoenix.O. the party who submitted the grievance will be notified of the review and resolution. parent or guardian.

Box 551188 Jacksonville.3 TriWest Healthcare Alliance Corp. such as accessibility. effectiveness. ACRONYMS SECTION 6 Filing a Grievance TRICARE North Region Submit your grievance in writing to: Health Net Federal Services.O. Box 86036 Phoenix. Inc. appropriateness. send your information to: Grievance Specialist ValueOptions P.healthnetfederalservices. Suite 400 San Antonio. continuity or timeliness of care. Box 870150 Surfside Beach.O. include the following information: • The beneficiary’s name.3 for details. LLC/TRICARE Grievance P.O.com Submit by fax: 1-888-317-6155 TRICARE South Region Submit your grievance in writing to: Regional Grievance Coordinator Humana Military Healthcare Services. address. LLC c/o PGBA. P. or outcome • The demeanor or behavior of providers and their staff • The performance of any part of the health care delivery system • Practices related to patient safety When filing a grievance.INFORMATION AND ASSISTANCE SECTION 5 Grievances may include such issues as: • The quality of certain aspects of health care or services. including: • The date and time of the event • Name of the provider(s) and/or person(s) involved • Location of the event (address) • The nature of the concern or complaint • Details describing the event or issue • Any appropriate supporting documents File your grievance with your regional contractor. level. FL 32255-1188 TRICARE West Region Submit your grievance in writing to: Figure 5. SC 29587-9750 Submit online at: www. and telephone number • Sponsor’s SSN • Beneficiary’s date of birth • Beneficiary’s signature • A description of the issue or concern. AZ 85080 33 . See Figure 5. Attn: Customer Relations Dept. 8123 Datapoint Drive. TX 78229 For behavioral health care concerns.

net • Report online at www.tricare. KY 40202 TRICARE West Region • Call 1-888-584-9378 • Fax 1-602-564-2171 • Report online at www. You also can access the TRICARE Program Integrity Web site at www.4 for details. 19th floor Louisville. and your most effective tool is your explanation of benefits (EOB). Inc. You also can report any fraud or abuse issues directly to TRICARE at fraudline@tma.mil/fraud for direct links to each contractor’s fraud and abuse reporting office. Reporting Fraud and Abuse TRICARE North Region • Call 1-800-977-6761 • Send an e-mail message to: program_integrity@health.4 34 . Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.triwest.healthnetfederalservices.Reporting Suspected Fraud and Abuse Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit or compensation. You are an important partner in the ongoing fight against fraud and abuse.com • Mail information to: Humana Military Healthcare Services. Report pharmacy program fraud or abuse by calling 1-800-332-5455..mil. Report suspected fraud and abuse to your regional contractor. it is one of the first lines of defense against health care fraud.com • Mail information to: Health Net Federal Services. LLC Attn: Program Integrity P. Attention: Program Integrity 500 West Main St. SC 29587-9747 TRICARE South Region • Call 1-800-333-1620 • Report online at www.O. Since an EOB is a tangible statement of services/supplies received.osd. Each EOB provides a toll-free number to call if you have questions about services you believe are billed fraudulently. See Figure 5.humana-military. We strongly encourage you to read your EOBs carefully.com Figure 5. Box 870147 Surfside Beach.

Acronyms ADA BCAC CHCBP DEERS DME DoD DRG DSO ECHO EOB MTF NDC OHI POC RTC SNF SSN TAMP TAO TDP TGRO TLAC TOP TPR TPRADFM TRO TRS TSC USFHP WPS American Diabetes Association Beneficiary Counseling and Assistance Coordinator Continued Health Care Benefit Program Defense Enrollment Eligibility Reporting System Durable Medical Equipment Department of Defense Diagnosis-related Group Defense Manpower Data Center Support Office Extended Care Health Option Explanation of Benefits Military Treatment Facility National Drug Code Other Health Insurance Point of Contact Residential Treatment Center Skilled Nursing Facility Social Security Number Transitional Assistance Management Program TRICARE Area Office TRICARE Dental Program TRICARE Global Remote Overseas TRICARE Latin America and Canada TRICARE Overseas Program TRICARE Prime Remote TRICARE Prime Remote for Active Duty Family Members TRICARE Regional Office TRICARE Reserve Select TRICARE Service Center US Family Health Plan Wisconsin Physicians Service ACRONYMS SECTION 6 35 .

” Written calls or orders to active duty will specify if they are in support of a contingency operation. Monthly premium payments and payments for non-covered services are not credited toward the catastrophic cap. Defense Enrollment Eligibility Reporting System (DEERS) A database of uniformed services members (sponsors). 12304. or was at the time of the member’s or former member’s death. or 12406 of this title [10]. & (I) quoted below.mil/bcac. or was at the time of the member’s or . Continued Health Care Benefit Program (CHCBP) A premium-based health care program you may purchase after the loss of TRICARE eligibility if you qualify. or unmarried person as specified in 10USC1072 (2)(A). 12301 (b). 12305. Catastrophic Cap The maximum amount TRICARE beneficiaries are required to pay out of pocket for deductibles and cost-shares each federal fiscal year (October 1–September 30). Nonparticipating providers may charge up to 15 percent above the TRICARE-allowable charge. Beneficiaries are required to keep DEERS updated. is enrolled in a full-time course of study at an institution of higher learning approved by the administering Secretary and is. or any other provision of law during a war or during a national emergency declared by the President or Congress. and others worldwide who are entitled under law to military benefits. 12302. Beneficiary Counseling and Assistance Coordinator (BCAC) Persons at military treatment facilities and TRICARE Regional Offices who are available to answer questions. including TRICARE. Covered Family Member An eligible family member (see “Eligible Family Member” definition on this page) enrolled in TRICARE Reserve Select. DEERS is the official system of record for TRICARE eligibility. or retention of. or (iii) is incapable of self-support because of a mental or physical incapacity that occurs while a dependent of a member or former member under clause (i) or (ii) and is. and assist beneficiaries in obtaining medical care through TRICARE. Deductible The annual amount a TRICARE Reserve Select beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. Cost-share A cost-share is the percentage or portion of costs that the beneficiary will pay for inpatient or outpatient care. (A) spouse. The CHCBP offers temporary transitional health coverage and must be purchased within 30 days after TRICARE eligibility ends. (ii) has not attained the age of 23. active duty of members of the uniformed services under 36 section 688. in fact dependent on the member or former member for over one-half of the child’s support. (D) a child who: (i) has not attained the age of 21. To locate a BCAC. family members. visit www. Participating providers are prohibited from balance billing. The cap applies to all TRICARE-covered services based on TRICARE-allowable charges. Eligible Family Member Spouse. child. (D). chapter 15 of this title [10]. help solve health care-related problems.tricare.Glossary Balance Billing A term used to describe instances when a provider bills a beneficiary for the difference between billed charges and the TRICAREallowable charge after TRICARE (and other health insurance) has paid everything it’s going to pay. Contingency Operation “A military operation that (a) results in the call or order to.

to accept payment directly from TRICARE. less any applicable patient cost-share paid by you. TRICARE pays second after all other health plans except for Medicaid. 37 Network Provider (also known as TRICARE Network Provider) TRICARE network providers have signed an agreement with your regional contractor to provide care at a negotiated rate. also known as “accepting assignment. an explanation of denial is provided. less any applicable patient cost-shares paid by you. and (v) is not a dependent of a member or a former member under any other subparagraph. in fact dependent on the member or former member for over onehalf of the child’s support. TRICAREauthorized providers have not agreed to accept the TRICARE-allowable charge or file your claims. (II) has not attained the age of 23 and is enrolled in a full-time course of study at an institution of higher learning approved by the administering Secretary. Network providers handle claims for you. to accept payment directly from TRICARE. and to accept the amount of the TRICARE-allowable charge. (I) an unmarried person who: (i) is placed in the legal custody of the member or former member as a result of an order of a court of competent jurisdiction in the United States (or a Territory or possession of the United States) for a period of at least 12 consecutive months. Negotiated Rate The rate network providers and participating non-network providers have agreed to accept for covered services. This amount is your responsibility and will not be shared by TRICARE. Explanation of Benefits (EOB) A statement sent to beneficiaries showing that claims were processed and the amount paid to providers. and to accept the TRICARE-allowable charge. TRICARE-authorized providers have not signed an agreement with your regional contractor and are therefore “out of network. as payment in full for their services.) Military Treatment Facility (MTF) A medical facility (hospital. (ii) either: (I) has not attained the age of 21.) owned and operated by the uniformed services usually located on or near a military base. Participate on a Claim When TRICARE-authorized providers participate on a claim. Other Health Insurance (OHI) Any non-TRICARE health insurance that is not considered a supplement acquired through an employer. Nonparticipating Non-network Provider Nonparticipating.” they agree to file the claim for you. the Indian Health Service. TRICARE supplements. (Refer to the Appendix section for samples of EOB statements. GLOSSARY APPENDIX SECTION 7 SECTION 8 .” There are two types of non-network providers: participating and nonparticipating. or other programs or plans as identified by the TRICARE Management Activity. (iv) resides with the member or former member unless separated by the necessity of military service or to receive institutional care as a result of disability or incapacitation or under such other circumstances as the administering Secretary may by regulation prescribe.former member’s death. Participating Non-network Provider Participating providers have agreed to file claims for you. clinic. or (III) is incapable of self support because of a mental or physical incapacity that occurred while the person was considered a dependent of the member or former member under this subparagraph pursuant to subclause (I) or (II). Nonparticipating providers may charge you up to 15 percent above the TRICARE-allowable charge for services. Non-network Provider Non-network. entitlement program. If denied. etc. (iii) is dependent on the member or former member for over one-half of the person’s support. or other source. non-network.

surgical. Employer-sponsored health insurance is not considered a TRICARE supplement. Regional Contractor A TRICARE civilian partner who provides health care services and support in the TRICARE regions (Health Net Federal Services. you are responsible for the full cost of care. Transitional Assistance Management Program (TAMP) Transitional health care for certain uniformed services members (and eligible family members) who separate from active duty. 38 . Humana Military Healthcare Services.). Providers may participate on a claim-byclaim basis. and pharmacies. hospitals. Prior Authorization A process of reviewing certain medical. ancillary providers (laboratories and radiology centers). meaning they may choose to participate on one claim. It will pay second after TRICARE. and behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission.. LLC. TRICARE-allowable Charge The maximum amount TRICARE will pay for services. TRICARE-authorized providers include doctors. but not another. Visit your TRICARE regional contractor's Web site for a list of services that require prior authorization.as payment in full for their services. There are two types of TRICARE-authorized providers: network and non-network. Inc. If you see a provider who is not TRICARE-authorized and can never be certified. TRICARE Network Provider See Network Provider TRICARE Supplement A health plan you may purchase specifically to supplement your TRICARE Reserve Select coverage. TRICARE-authorized Provider A provider who meets TRICARE’s licensing and certification requirements and has been certified by TRICARE to provide care to TRICARE beneficiaries. and TriWest Healthcare Alliance Corp.

1 • South Region: Figure 8.3 APPENDIX SECTION 8 39 . • North Region: Figure 8.2 • West Region: Figure 8.Appendix Sample Explanation of Benefits Statements The following pages list figures and reference details for each regional contractor’s explanation of benefits (EOB) statements.

North Region Explanation of Benefits Statement Sample Figure 8.1 40 .

A Check Number will appear here only if a check accompanies your EOB. Regional Contractor—The name “Health Net Federal Services” and the Health Net logo will appear here. Beneficiary Liability Summary—You may be responsible for a portion of the fee your doctor has charged. 8. You will find the following totals: amount billed. 6. It also lists the specific procedure codes that doctors. 41 13. Mail-to Name and Address—We mail the TRICARE EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. benefits we have paid to the provider. See Remarks—If you see a code or a number here. or lab charged this fee for the medical services you received. LLC—PGBA processes all TRICARE claims for the region where you live. retired. 4. 2. or deceased) who is your TRICARE sponsor. Our professional customer service representatives will gladly assist you. Patient Responsibility—The total amount you owe for this claim. Benefit Period Summary—This section shows how much of the individual and family annual deductible and maximum out-of-pocket expense you have met to date. look at the Remarks section (18) for more information about your claim. amount approved by TRICARE. 18.) 7. APPENDIX SECTION 8 . National Guard. hospital. amount (if any) that you have already paid to the provider. We calculate your annual deductible and maximum out-of-pocket expense by fiscal year. and labs use to identify the specific medical services you received. hospitals. If so.How to Read Your TRICARE EOB for the North Region 1. you’ll see that amount itemized here. 15. 9. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. It also helps us find the claim quickly whenever you call or write us with questions or concerns. Service Provided By/Date of Services— This section lists who provided your medical care. 3. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number of the military service member (active duty. 16. 14. 17. Beneficiary Name—The patient who received medical care and for whom this claim was filed. Remarks—Explanations of the codes or numbers listed in See Remarks will appear here. Services Provided—This section describes the medical services you received and how many services are itemized on your claim. 10. 11. non-covered amount. It will include any charges that we have applied to your annual deductible and any cost-share or copayment you must pay. and benefits we have paid to the beneficiary. Amount Billed—Your doctor. This means the doctor accepts the TRICARE maximum allowable charge as payment in full for the services you received. TRICARE Approved—This is the amount TRICARE approves for the services you received. (Note: Be sure your doctor has updated your records with your current address. as well as the date you received the care. 5. Benefits Were Payable To—This field will appear only if your doctor accepts assignment. This helps us keep track of the claim as it is processed. PGBA. amount your primary health insurance paid (if TRICARE is your secondary insurance). Claim Number—We assign each claim a unique number. 12. Date of Notice—PGBA prepared your TRICARE EOB on this date. Reserve. the number of services and the procedure codes. Toll-Free Telephone Number—Questions about your TRICARE explanation of benefits? Please call PGBA toll-free at 1-877-TRICARE (1-877-874-2273). See the Fiscal Year beginning date in this section for the first date of the fiscal year. 19.

South Region Explanation of Benefits Statement Sample Figure 8.2 42 .

you’ll see that amount itemized here. We calculate your annual deductible and maximum out-of-pocket expense by fiscal year. This means the doctor accepts the TRICARE allowable charge as payment in full for the services you received. look at the Remarks section (17) for more information about your claim. amount your primary health insurance paid (if TRICARE is your secondary insurance). PGBA. Regional Contractor—The name “Humana Military” and the Humana Military logo will appear here. Toll-Free Telephone Number—Questions about your TRICARE explanation of benefits? Please call PGBA at this toll-free number. hospital. Amount Billed—Your doctor. 3. only the last four digits of your sponsor’s SSN will appear on the EOB. If so. Mail-to Name and Address—We mail the EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. and the procedure codes. or deceased) who is your TRICARE sponsor. Service Provided By/Date of Services— This section lists who provided your medical care. 8. APPENDIX SECTION 8 43 . This helps us keep track of the claim as it is processed. Date of Notice—PGBA prepared your TRICARE EOB on this date. (Note: Be sure your doctor has updated your records with your current address. It will include any charges that we have applied to your annual deductible and any cost-share or copayment you must pay. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. non-covered amount. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number (SSN) of the military service member (active duty. hospitals.How to Read Your TRICARE EOB for the South Region 1. See the Fiscal Year beginning date in this section for the first date of the fiscal year. 18. 13. 16. 17. and benefits we have paid to the beneficiary. Benefits Were Payable To—This field will appear only if your doctor accepts assignment. amount that you have already paid to the provider (if any). as well as the date you received the care. Beneficiary Name—The patient who received medical care and for whom this claim was filed. benefits we have paid to the provider. and labs use to identify the specific medical services you received. See Remarks—If you see a code or a number here. amount approved by TRICARE. Remarks—Explanations of the codes or numbers listed in the “See Remarks” section will appear here. For security reasons. 14. Services Provided—This section describes the medical services you received and how many services are itemized on your claim. 15. the number of services. Our professional customer service representatives will gladly assist you. retired. TRICARE Approved—This is the amount TRICARE approves for the services you received. 4. LLC—PGBA processes all TRICARE claims for the region where you live. Claim Number—We assign each claim a unique number.) 7. You will find the following totals: amount billed. A check number will appear here only if a check accompanies your EOB. or lab charged this fee for the medical services you received. 5. 6. It also lists the specific procedure codes that doctors. 2. 11. Beneficiary Liability Summary—You may be responsible for a portion of the fee your doctor has charged. 9. 10. It also helps us find the claim quickly whenever you call or write us with questions or concerns. 12. Benefit Period Summary—This section shows how much of the individual and family annual deductible and maximum out-of-pocket expense you have met to date.

West Region Explanation of Benefits Statement Sample Figure 8.3 44 .

18. It also helps us find the claim quickly whenever you call or write us with questions or concerns. Service Provided By—Who provided your medical care. Check Number—A Check Number will appear here only if a check accompanies your EOB. amount (if any) that you have already paid to the provider. (Note: Be sure your doctor has updated your records with your current address. See the Fiscal Year Beginning date in this section for the first date of the fiscal year. Date of Services—The date you received the care. 5. Date of Notice—The date we prepared your TRICARE EOB. 9. Beneficiary Share—You may be responsible for a portion of the fee your doctor has charged. 3. You will find the following totals: amount billed.” and the TriWest logo will appear here. hospital. 16. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number of the military service member (active duty. It will include any charges that we have applied to your annual deductible and any cost-share or copayment you must pay. and the procedure codes. 13. 15. amount approved by TRICARE. 4. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. We calculate your annual deductible and maximum out-of-pocket expense by fiscal year. 14. Amount Billed—The fee charged by your doctor. 12. 6. benefits we have paid to the beneficiary. you’ll see that amount itemized here. or lab for the medical services you received. Toll-Free Number/Web Address—How you can reach us (TriWest) if you have questions. 10. benefits we have paid to the provider. INDEX APPENDIX SECTION 10 SECTION 8 . 17. This helps us keep track of the claim as it is processed. Mail-to Name and Address—We mail the TRICARE EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. non-covered amount. Regional Contractor— The name “TriWest Healthcare Alliance Corp. If so. retired. look at the Remark Codes in section (16) for more information about your claim. Paid To—The name of the provider or facility to whom the claim was paid.) 2. TRICARE Allowed—This is the amount TRICARE approves for the services you received. amount your primary health insurance paid (if TRICARE is your 45 secondary insurance). or deceased) who is your TRICARE sponsor. 11. 8. Remarks—If you see a code or a number in this section. Remark Codes—Explanations of the codes or numbers listed in Remarks (12) will appear here. Claim Number—We assign each claim a unique number. Patient Name—The patient who received medical care and for whom this claim was filed. 7.How to Read Your TRICARE EOB for the West Region 1. the number and type of services. Out of Pocket Expense—This section shows how much of the individual and family annual deductible and maximum out-of-pocket expense you have met to date.

. . . . . .44 46 . . . . . . . . . .6 TRS Wallet Card (front) . . . . . . . . . . . . . . . . . .42 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . .1 8. . .1 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 8. . . . . . . . . . . . . . .32 Filing a Grievance . . . . . . . . . . . . . . . . .2 5. . . . . . . . . . . . . . .1 5. .3 5. . . . .4 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 South Region Explanation of Benefits Statement Sample . . . . .7 Outpatient Services: Coverage Details . . . . . . . .31 Regional Appeals Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 North Region Explanation of Benefits Statement Sample . . . .2 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Services or Procedures with Significant Limitations . . . . .2 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 2. . . . .1 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1. . . . . . . .22 Overseas Claims Addresses . . . .2 1. . .2 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 TRICARE Appeal Requirements . . . . . . . . . . . . . . . .9 Inpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . .3 2. . . . . . . . . . . . . . . . .33 Reporting Fraud and Abuse . .17 Regional Claims Processing Information . . . . . . . . . . . . . . . . . . . . . . .10 Behavioral Health Care Services: Coverage Details .5 3. . . . . . . . .10 Clinical Preventive Services: Coverage Details .7 TRS Wallet Card (back) . . . .List of Figures Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure 1. . . . . . . . . . . . . . . . . . .

26-27. 11. 10 Cardiac rehabilitation. 18-19 Coverage. 26-27. 21. 18 Cancer. 43. 37 Clinical preventive services. 7. 14. 22-24. 10. 6. 36. 16 Detoxification. 19-20 Disabilities. 33 Beneficiary. 10. 8 Admission(s). 36-37 Cranial orthotic device. 26 Chiropractic care. 17 Contingency operation. 17 Custodial care. 17 Adjunctive dental services. 38 Adoption. 17 Chair lifts. 9-17. 21. 34. 32-33 Birth control. 36 Certificate of creditable coverage. 28. 9. 17. 19. 23. 18. 20 Cancer screening. 36-37. 9. 18 Brand name. 26-30. 31-32 Arch supports. 18 Assistance coordinator.LIST OF FIGURES SECTION 9 Index A Abortion. 17 Catastrophic cap. 12 Adjunctive dental care. 18 Acute inpatient psychiatric care. 19. 11. 45 Cost-share. 30. 29-30. 26 Defense Enrollment Eligibility Reporting System (DEERS). 11. 14-15. 7-8. 9 Ambicabs. 9 Ambulance. 31-32. 18 Diagnostic tests. 11-14. 28 Certificate of Recognition. 45 Birth. 15 Breast cancer. 19 Breast pumps. 30-33. 17 Authorized provider. 1. 6. 13. 14 Diabetes. 8-13. 30. 8. 21. 17-19. 37-38 Autopsy services. 12. 43. 7. 14. 19 Child. 17 Claim. 43. 18 Artificial insemination. 30. 21. 10 Bone marrow transplants. 9-10. 10. 19. 1. 36. 17 Blood products. 18-19. 10-11. 13. 41. 19 Custodial parent. 20 American Diabetes Association. 36 Copayment. 41. 18 Disability. 15. 26-27 Allergy test. 23-24. 10 Contact lenses. 19. 31 D Death of a spouse. 32. 21-24. 10. 10 Blood pressure screening. 45 Beneficiary counseling and assistance coordinators (BCAC). 19. 30-32. 37 INDEX INDEX SECTION 10 SECTION 10 47 . 10-12. 30 Denial. 23-24. 1. 19-20 Colorectal cancer. 45 Clinic. 7. 23. 12. 19. 36 Continued Health Care Benefit Program (CHCBP). 28. 24 Acupuncture. 10. 36-37 Children. 35 Attending physician. 17 Ancillary services. 18 Brace. 17. 16. 17-18 Dental services. 6-8. 26-27. 24. 36 Defense Manpower Data Center Support Office (DSO). 43. 38 Covered services. 18 B Behavioral health care. 31. 24. 18 Annual deductibles. 17 Abuse. 41. 8. 1. 26. 17-19 Diagnosis-related group (DRG). 23-24. 17 C Camps. 10 Breastfeeding. 37 Dental care. 27-28. 15-21. 41. 36 Billed. 18 Birth defect. 20 Cardiovascular disease. 16. 43. 34 Accident. 36. 9 Anesthesia. 10. 31-32. 41. 1 Appeal. 37-38. 12-13. 45 Counseling.

19 Medication management.Disease. 39. 8-13. 18-19 Exclusions. 17 F Family member. 9-10. 1. 8. 11-14. 18-19. 18 Grievance. 11. 7. 10 Home health services. 18 Gastric bypass. 14 Durable medical equipment (DME). 11. 36 Examinations. 15-16. 36. 10 Influenza vaccine. 17 Infectious disease. 1. 10 Marriage. 15-21 Explanation of benefits (EOB). 9 Medical facility. 7. 10. 45 Eyeglasses. 7 End-stage renal disease. 1. 37 Infant. 1. 17 Electrocardiograms. 10 In-vitro fertilization. 13 H Hepatitis B screening. 9. 31. 17 L Laboratory. 12-14. 32-33 Group sessions. 45 Food. 30. 10 Eligibility. 14-16. 15-16 Generic medications. 1. 18 K Keratoconus. 19 Licensed professional counselors. 8-19 Line-of-duty care. 10 Inpatient admissions. 41. 18 Fraud and abuse. 17 48 . 8-9 Hospice care. 37 Molding helmet. 37. 19. 37 Medical insurance. 11 Limitations. 2. 18 Food substitutes. 16. 12 Inpatient behavioral health care. 27 Fiscal year. 12. 19 Infantile glaucoma. 43. 38 Medicare. 18-19. 10. 36. 34 G Gamete intrafallopian transfer. 10 Medicabs. 10. 1. 36 Emergency care. 23 Disorder. 10-11. 41. 30 Medications. 43. 14. 13. 10. 21. 17. 23. 38 Family therapy. 18 General nursing. 27-28 M Mammograms. 18 Divorce. 31 Inpatient psychotherapy. 18 Enrollment. 10. 7. 24-25. 19 Medical necessity. 18 Learning disability. 8 Hospitalization. 20 LASIK. 26. 9 Dyslexia. 37 Indian Health Service. 12 Hospitals. 10 Human papillomavirus (HPV). 9. 19 E Extended Care Health Option (ECHO). 8. 11 I Immunizations. 7. 16 Maternity services. 18-19. 23. 8 Education. 15 Genetic testing. 15 Generic equivalent(s). Human immunodeficiency virus (HIV). 20 Laboratory services. 43. 30. 13 Inpatient services. 26-30. 10 Generic drug use policy. 26-27 Drug abuse. 23 Loss of eligibility. 9. 18 Gastroplasty procedures. 38. 7. 41. 27-31. 19 Incapacitation. 30 Maternity. 6. 10. 34. 16 Meals. 13-14 Federal Employees Health Benefits program. 12 Military treatment facility (MTF). 16 Maternity ultrasounds. 31.

20 Parenteral. 8 Outpatient care. 45 Rehabilitation. 21. 1. 19 Psychological disorders. 26-27. 11 Nonemergency. 16 Pregnancy. 30. 15 R Radiology services. 15-19. 17 Outpatient psychotherapy. 31. 1. 43. 22. 6-9. 13 Outpatient services. 24. 38 Newborn. 11 Rubella. 9-10 Physician. 15. 23. 11 Refractive corneal surgery. 22-24. 12 Psychologist. 26. 6. 21. 15-16 Non-network pharmacy. 11. 22 Non-network provider. 19 Orthopedic shoes. 17 Purchase lockout. 19 Physical therapy. 10. 14-15. 36-37 Pastoral counselor. 45 Referral. 16 Prescribing provider/physician. 13 Psychotherapy. 36-38. 19 Postpartum care. 24. 12. 28-29 Prenatal care. 30 Residential treatment center (RTC). 17. 11. 10. 11-14. 9-10. 41. 6. 14-15. 24 Preventive care. 31-32. 10 Radiology. 12-13. 10. 9 Provider(s). 24. 15.INDEX SECTION 10 N National Guard and Reserve. 22. 31 Non-covered behavioral health care services. 19. 17. 19 Regional contractor. 14-16. 19 Necessary mastectomy. 13 Retail pharmacies. 18. 20 Patient information. 10 Rubella antibodies. 31. 1. 43. 31-32 Reconstructive surgery. 21. 43. 1. 19 Psychiatrist. 17. 6. 37-38. 3. 6. 18 Non-appealable issue(s). 6-9. 9 P Pap smears. 38 Prostate cancer. 10 Prosthetic devices. 17 Nutrition. 22-24 Remote locations. 6-8. 12-14. 23. 26 Non-adjunctive dental treatment. 30 Naturopaths. 36-37 Nonsynostic positional plagiocephaly. 15 Rh immune globulin. 17 Network pharmacies. 1. 23 Reserve Affairs Web site. 37 Nonparticipating provider. 12 Partial hospitalization. 36 Outpatient behavioral health. 38 Reconsideration. 15. 45 Psychiatric treatment. 8. 14. 19. 12 Non-formulary drugs. 36-37 Outpatient. 19-20. 41. 21-23. 41. 13 Psychogenic. 22-24. 9 Orthomolecular psychiatric therapy. 8. 13-14. 18 O Obesity. 19 INDEX SECTION 10 . 13 Psychoanalysis. 1. 9 Pharmacy. 30-34. 2. 18 Partial day treatment. 16-17. 9. 21-24. 8-11. 37. 12 Partial reimbursement. 36 Outpatient diabetic self-management. 13 Psychological testing. 10 Routine osteoporosis screening. 6. 11 Pathological services. 19 Pulmonary rehabilitation. 31 Plastic surgery. 13 Postpartum. 9. 18 Osteopathic manipulation. 34 Phase III cardiac rehabilitation. 16-18 Premiums. 11-12. 9 Other health insurance (OHI). 17 Records. 11. 16. 18-19 Occupational therapy. 19 Preventive therapy. 15 Network provider. 31-34. 8. 10 Prior authorization. 21. 6. 6. 22 Prescription. 17 Physical examination. 8. 31-32 Nonavailability statements (NAS). 11-15. 17 49 Play therapy. 17 Reimbursement. 8. 15-17. 15. 9 Routine preventive procedure. 24 Participating provider. 22. 10 Runaway child. 22 Personal physician. 27-28 Q Quantity limits.

23 TRICARE Pacific. 10 Vision screening. 41. 28 Transplants. 37 TRICARE Mail Order Pharmacy. 26. 10 Transfers. 9. 22-23. 29 Survivor coverage. 19 Sexual inadequacy treatment. 8. 8 Sterilization reversal surgery. 12. 9 Survivor. 45 Spas. 37 TRICARE Overseas Program (TOP). 6-7. 8. 10 Supplements. 17-21. 14-15 TRICARE Management Activity (TMA). 32-33. 30 United Concordia Companies. 10 Substance use disorder. 3. 41. 29 Swimming pools. 24 Tobacco. Inc. 10. 1. 23. 18. 23. 18 Skilled nursing facility. 22-23 TRICARE Prime. 8. 9 Tests. 14 Suicide risk assessment. 21 50 Treatment. 11. 10 Spouse. 11. 43 TRICARE-authorized provider. 34. 36-37 TRICARE-allowable charge. 1. 17 Serious injury. 16 US Family Health Plan (USFHP). 30. 16-17. 2-3. 19 T Taxi service. 9-10 Skin. 21. 36. 36-38. 19 Shoe inserts. 1 TRICARE Prime Remote (TPR). 10 Third-party liability. 37 Surgical care. 21. 7. 26-30. 1. 1. 28. 9-10 Speech pathology services. 18 Substance abuse. 36-38 Uniformed services identification (ID) card. 43. 26 TRICARE regions. 28. 12. 11 Smoking. 1 V Vaccines. 30 TRS Request form. 2-3. 6. 14 Stem cell.S Safe sexual practices. 15 TRICARE Retail Pharmacy. 18 Traveling. 31 Uniformed services. 34 Unauthorized provider. 23 TRICARE Europe. 27. 2. 21.. 2-3. 30 TRICARE Dental Program. 36 Sponsor. 9 Speech therapy. 32-33. 19-20 Tetanus. 10 Speech. 10 Vitamins. 12-14. 23 TRICARE Point of Contact. 1. 1 TRICARE regional contractor. 8. 31. 8. 7 TRICARE retail network pharmacy. 26-28. 30. 18 . 10 U Ultrasounds. 36. 9 Transitional Assistance Management Program (TAMP). 1. 38 TRICARE Reserve Select wallet card. 23. 18. 30-31. 29 Tuberculosis. 23. 37-38 TRICARE Area Office (TAO). 9. 38 Transitional medical coverage. 18 Stress management. 9 Sexual dysfunction. 9. 26. 24 TRICARE Service Center (TSC). 9. 17 Serious medical condition. 27 Serious birth defect. 19 Social Security number (SSN). 21. 38 TRICARE Reserve Select (TRS). 2. 19 Stress. 1 TRICARE formulary search tool. 10 School physicals. 3. 23 TRICARE Extra. 19. 9-10. 16. 26-27. 1 TRICARE Global Remote Overseas (TGRO). 33 Special care units. 8. 18 Vocational counseling. 11 Selected Reserve. 19 Specialist. 10 Special diets. 23. 16 TRICARE Latin America and Canada (TLAC). 23-24. 6. 24. 1-2. 21. 3. 7. 7. 16 Unauthorized benefit. 45 Stabilization. 43.

14 Weight loss. 17 INDEX SECTION 10 51 . 18-19 Whirlpools. 19 Wisconsin Physicians Service (WPS). 22 X X-rays.W Waiver. 10.

Notes 52 .

com Questions? Questions? www. bill no more than 15% above allowable charge. SC 29020 7031 1 877 298 3408 www.mil/cmac/ for allowable amount. Box 77028 Madison. WI 53707 7985 1 608 301 2310 www.com Questions? Questions? .TRICARE Reserve Select Europe Overseas Providers TRICARE Reserve Select North Region Network Providers O V E R S E A S N E T W O R K Collect Cost Share: 20% of TRICARE allowable charge By law. bill no more than 15% above allowable charge. Box 7031 Camden.triwest.O. LLC c/o PGBA.healthnetfederalservices. Submit Claims To: WPS—Overseas Claims P. LLC/TRICARE P.O. bill no more than 15% above allowable charge. Visit www. Box 7985 Madison.O.com TRICARE Reserve Select Pacific Overseas Providers TRICARE Reserve Select West Region Network Providers O V E R S E A S Collect Cost Share: 20% of TRICARE allowable charge By law.com N E T W O R K Collect Cost Share: 15% of negotiated rate Submit Claims To: West Region Claims WPS P.TRICARE4u. SC 29587 9740 1 800 555 2605 www. Submit Claims To: WPS—TRICARE Overseas Claims P. Visit www.O. Submit Claims To: WPS—Overseas Claims P. WI 53707 1028 1 888 TRIWEST www.O.O. WI 53708 8976 1 608 301 2310 www. Box 8976 Madison.TRICARE4u.tricare.com Collect Cost Share: 15% of negotiated rate Submit Claims To: Health Net Federal Services.humana military. WI 53707 7985 1 608 301 2310 www. Visit www.com www.mil/cmac/ for allowable amount.com Questions? Questions? TRICARE Reserve Select O V E R S E A S N E T W O R K Latin America and Canada Overseas Providers TRICARE Reserve Select South Region Network Providers Collect Cost Share: 20% of TRICARE allowable charge By law.myTRICARE.tricare.mil/cmac/ for allowable amount. Box 7985 Madison.com Collect Cost Share: 15% of negotiated rate Submit Claims To: TRICARE South Region Claims Department P.myTRICARE.tricare. Box 870140 Surfside Beach.TRICARE4u.

bill no more than 15% above allowable charge. LLC/TRICARE P. along with your TRICARE Reserve Select (TRS) wallet card.com Questions? If you have never treated a TRICARE beneficiary. Presenting both cards at the time of care will help ensure that your provider processes your claims correctly.mil/cmac/ for allowable amount. bill no more than 15% above allowable charge.tricare. bill no more than 15% above allowable charge.com Questions? If you have never treated a TRICARE beneficiary. Collect Cost Share: 20% of TRICARE allowable charge By law. Box 77028 Madison. TRICARE Reserve Select N O N . N O N .O.tricare. The cards on this page are not meant to replace your TRS wallet card.N E T W O R K TRICARE Reserve Select South Region Non-Network Providers Collect Cost Share: 20% of TRICARE allowable charge By law. Submit Claims To: Health Net Federal Services. and present it. contact Humana Military to become a certified provider to ensure claims are processed smoothly.O. stateside regions are on the right—carry it with you at all times. Box 7031 Camden. WI 53707 1028 1 888 TRIWEST www.N E T W O R K West Region Non-Network Providers Collect Cost Share: 20% of TRICARE allowable charge By law.tricare. SC 29020 7031 1 877 298 3408 www. SC 29587 9740 1 800 555 2605 www. Submit Claims To: West Region Claims WPS P.O.com Questions? If you have never treated a TRICARE beneficiary. Submit Claims To: TRICARE South Region Claims Department P. LLC c/o PGBA. Visit www. and regional contractors. contact Health Net to become a certified provider to ensure claims are processed smoothly. Visit www. claims. Visit www. .mil/cmac/ for allowable amount.N O N . which serves as proof of TRICARE coverage. Punch out the perforated card for the region in which you reside—overseas regions are on the left. when you receive care.healthnetfederalservices.humana military.N E T W O R K TRICARE Reserve Select North Region Non-Network Providers Using These Cards These quick fact cards are designed to give providers at a glance information about your TRICARE cost shares. Box 870140 Surfside Beach.mil/cmac/ for allowable amount.triwest. contact TriWest to become a certified provider to ensure claims are processed smoothly.

• Have a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care. copy. You also have the responsibility to: • Show respect for other patients and health care workers. and request amendments to your medical records. or source of payment. and facilities. and maintaining a healthy diet. and to fully participate in all decisions related to your health care. age.tricare. medical professionals. • Have a fair and efficient process for resolving differences with your health plan. sexual orientation. • Communicate with health care providers in confidence and to have the confidentiality of your health care information protected. • Receive considerate. you have the right to: • Receive accurate. you have the responsibility to: • Maximize healthy habits.You also have the right to review. health care providers. such as exercising. ethnicity. treatment. national origin. mental or physical disability. • Make a good-faith effort to meet financial obligations. • Receive and review information about diagnosis.Patient Bill of Rights and Responsibilities As a patient in the military health system. disclosing relevant information. easy-to-understand information to help you make informed decisions about TRICARE programs. and the institutions that serve them.mil/evaluations/feedback. which means working with providers in developing and carrying out agreed-upon treatment plans. Please provide feedback on this handbook at http://www. Printed: October 2007 . or to be represented by family members. • Use the disputed claims process when there is a disagreement. and clearly communicating your wants and needs. visit www.tricare. • Be knowledgeable about TRICARE coverage and program options. For more information about your rights. As a patient in the military health system. respectful care from all members of the health care system without discrimination based on race. or other duly appointed representatives. genetic information.mil/Patientrights/default. • Report wrongdoing and fraud to appropriate resources or legal authorities. sex. • Be involved in health care decisions. • Access emergency health care services when and where the need arises. and the progress of your condition. religion.cfm. conservators. not smoking.

1-888-TRIWEST (1-888-874-9378) TRICARE Overseas (TRICARE Europe.www. LLC 1-800-555-2605 Humana Military Healthcare Services. and TRICARE Pacific) 1-888-777-8343 TRICARE Mail Order Pharmacy 1-866-DoD-TMOP (1-866-363-8667) TRICARE Retail Network Pharmacy 1-866-DoD-TRRX (1-866-363-8779) HA661BET10074 . Inc. 1-800-444-5445 TriWest Healthcare Alliance.tricare.mil/reserve/reserveselect Health Net Federal Services. Corp.TRICARE Latin America and Canada.

Sign up to vote on this title
UsefulNot useful