Whether you or your provider files a claim for payment of your medical bills under TRICARE, you need to know some basic rules to avoid claims processing problems. (For a brief explanation, go to 10 Steps to a Health Claim.)
TRICARE participating providers are required to file claims for beneficiaries, and providers submit 97 percent of all TRICARE claims. However, if the provider is non-participating, you may need to file the claim.
You or your provider should submit claims as soon as possible after the delivery of care. They must be filed within one year of the date of service, or within one year of the date of an inpatient discharge.
When you file a claim, submit it using DD Form 2642 (patient's request for medical payment). Forms are available :
- Military Health System/TRICARE Web site.
- Beneficiary Counseling and Assistance Coordinators (BCACs) or health benefits advisers at military treatment facilities
- TRICARE regional contractors (or one of their TRICARE service centers)
- TRICARE Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9066
You may also need to include a non-availability statement for inpatient care (obtained from the MTF), an explanation of benefits (EOB), or denial, from other insurance. When filing a claim, include:
- Photocopies of fully itemized bills from the provider, showing the cost for each service or supply provided
- Patient's name, diagnosis or symptoms, place of service, number/frequency of each service, and date of care.
- Canceled checks or cash register receipts are not acceptable as itemized bills.
With claims for prescription drugs, you must include the pharmacy's billing form, showing the name, strength, amount and cost of each drug, prescription number, date filled, and the name and address of the prescribing doctor and the pharmacy.
A beneficiary who receives the services of a private duty nurse at home or in a hospital, must submit the nurse's daily notes with claims, the name of the doctor who is supervising the care, and prescriptions for medical supplies and durable medical equipment.
Claims submitted for someone in the Program for Persons with Disabilities must include a copy of authorization for services, and a list of supplies or equipment received.
Always include copies of receipts. Include the sponsor's Social Security number on all pieces of correspondence and attachments to claims. Circle information rather than use a highlighter or marker on documents. Before submitting the claim, make sure the correct claim form has been completed, double-check all information for completeness, provide signatures where necessary, and include all necessary documentation listed above.
Beneficiaries and providers must mail claims and the accompanying documentation to the TRICARE contractor for the region where the patient lives. Address for filing claims may be found in the beneficiary handbook or on the TRICARE Web site. Active duty service members stationed overseas, and their families, file claims with Wisconsin Physicians Service (WPS).
When all necessary information is submitted with the claim, contractors are required to complete processing within 30 days. When they need additional information, claims processors will call or write to the beneficiary or provider, who must supply the information requested before the claim can be processed. To avoid delays, keep copies of claims and the originals of all other documents sent to the claims processor or to TRICARE. When providers file claims, beneficiaries should keep copies of providers' bills.
Verify that your information is correct in the Defense Enrollment Eligibility Reporting System (DEERS) data bank. You can review information in your DEERS file at most offices that issue military identification cards.
You can also call DEERS, toll-free, at one of these numbers:
- 1-800-538-9552 (Continental U.S.)
- 1-800-334-4162 (California residents only)
- 1-800-527-5602 (Alaska and Hawaii residents only)
If you believe your claims has been incorrectly processed or denied, refer to instructions for disputing a decision and filing an appeal that appear on the back of every TRICARE explanation of benefits.
For more information about filing and appealing claims, check with a BCAC at a military treatment facility (MTF) or regional lead agent's office, with a health benefits adviser at the MTF, with a TRICARE service center representative, with the appropriate TRICARE managed care support contractor or with a debt collection assistance officer, if credit or collection issues are involved.
You may call claims processors at the following numbers to address claims problems:
- Palmetto Government Benefits Administrators (PGBA), 1-800-225-4816 - for all regions except Southwest (Texas - except the extreme western area, Oklahoma, the majority of Louisiana and Arkansas) and Northwest (Washington, Oregon and northern Idaho)
- WPS, 1-800-404-0110 -for Southwest and Northwest. Active duty personnel and their family members stationed overseas can call a WPS claims contractor at (608) 224-2727.
You can find information about claims by calling the TRICARE Contractor for Region 6, Foundation Health, at 1-800-444-5445.
page last modified on: 5/7/2013