Tricare Help: Why doesn’t Tricare pay for everything? - Getting out, military health issues - Navy Times

Tricare Help: Why doesn’t Tricare pay for everything?

Q. I had tests done last May. My doctor says Tricare didn’t pay for all of them, and I owe him $43. I sent him what Tricare paid me. Shouldn’t Tricare have to pay for everything?

A. The $43 could be one of three things: a denied service, your cost share or an amount credited to your deductible.

To find out whether it was a denied service, you’ll need to look at your explanation of benefits, which reports all of Tricare’s actions on the charges on the bill. If any charges on the claim were not paid, the EOB would have reported those charges and the reason for nonpayment, and informed you of your right to file an appeal within 90 days.

In an appeal, Tricare must re-examine the claim and the reasons for denial to make sure it followed all the rules established by law and regulation.

If the EOB reported that payment for a particular test was denied, the reason could have been something simple, such as a request for more information to justify the need for the test. Your doctor easily could have supplied it if you had told him what the EOB or the appeal decision said.

You wrote that you sent the doctor what Tricare paid you. Tricare’s payment would not have included your cost share or any amount credited to your deductible. Tricare’s rules say you are responsible for paying those amounts.

To get more help, write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO, 80011-9043. Include your full name and Social Security number, the doctor’s name and dates of care, copies of all bills, and a daytime phone number.

Q. I have applied for Social Security disability for one year when I will not be able to work for medical reasons. If I am awarded that benefit, do I have to enroll in Medicare Part B, become eligible for Tricare for Lifeand switch from Prime to Tricare Standard? When I return to work after a year, what must I do to re-enroll in Tricare Prime?

A. As I understand the rules for Social Security disability benefits, you will not become entitled to Medicare until you have received those benefits for 24 consecutive months. If you are awarded benefits for only 12 months, you will not be entitled to Medicare, and you will not have to enroll in Part B. There should be no effect on your Tricare Prime enrollment.

Although you have applied for Social Security disability benefits, you will not know the results until Social Security has completed its evaluation of your application and advised you in writing of its decision. Your actions at that time will be determined by the benefits you are awarded.

Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@militarytimes.com. In e-mail, include the word “Tricare” in the subject line and do not attach files. Get more Tricare advice at our Tricare Help blog.