Editor’s Note: This article by military and veterans reporter Patricia Kime, with contributions by Karen Ruedisueli, is part of MOAA’s 2021-22 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Mercer Consumer. A version of the guide appeared in the November 2021 issue of Military Officer magazine.
When your medical care isn’t going as you think it should or you have an unexpected bill, the Military Health System and TRICARE can be challenging to navigate.
“Health care coverage in general is complicated,” said Karen Ruedisueli, MOAA’s director of Government Relations for Health Affairs. “But the military health system has this unique aspect of direct care in military hospitals and clinics that can be unfamiliar for many younger military families and sometimes creates confusion about where to go for help.”
Most military beneficiary medical care and service problems fall into two main categories: issues that arise over medical treatment and concerns over coverage or related claims and payment disputes.
Knowing where to seek help starts with where you receive care.
If you are a patient in a military hospital or clinic, this is considered “direct care.”
Each main military medical center, along with its underlying clinics, has one or more patient advocates — also known as patient representatives — whose jobs are to support patients and families to resolve problems with care, staff, or administration.
Each hospital lists the contact number for their patient advocates on their websites and in facility directories. Patient advocates can help beneficiaries navigate the direct care system and understand their options or provide assistance with appeals up the chain of command.
Major military health facilities have instituted a Healthcare Resolutions program that provides a way for patients, family members, and providers to communicate in a setting facilitated by trained administrators. Check the medical facilities’ websites to locate these resources.
For non-Medicare eligible beneficiaries with concerns about medical care in TRICARE Prime, TRICARE Select, or other TRICARE programs, patients must know the TRICARE Region in which they are enrolled.
The TRICARE East Region is managed by Humana Military, and their phone number is (800) 444-5445. The number for TRICARE West – HealthNet Federal Services – is (844) 866-9378. For questions on billing, the TRICARE website has a Copayments and Cost Shares tool that provides information specific to TRICARE plan and sponsor status to give you an idea of what to expect.
If you receive a bill for an unexpected amount, you can consult your TRICARE Explanation of Benefits (EOB) on your TRICARE contractor’s website.
[AT TRICARE.MIL: Regional Contractor Contact Information]
The EOB details how much TRICARE has paid to your provider and how much you owe. You can also get this information by calling TRICARE customer service at the phone numbers for your region listed above.
For more complex issues with TRICARE benefits and billing, most MTFs have a beneficiary counseling and assistant coordinator available to provide information on enrollment, and to help with claims and billing issues. Phone numbers for these staff members can be searched using the TRICARE Customer Service Community Directory.
Patients may also contact their regional contractor with billing questions and can appeal to the Defense Health Agency for concerns about coverage. The same procedure goes for an appeal for most denials of medication. Patients can appeal to Express Scripts by mail.
For more on appeals, go to TRICARE.mil.
TRICARE For Life
Patients eligible for both Medicare and TRICARE for Life should consult their providers’ patient advocates for medical treatment issues or Medicare for a billing or claims dispute. The exception would be a dispute over payment for one of the few conditions only covered by TRICARE and not Medicare.
For issues with billing for these medical concerns, TFL beneficiaries should contact the contractor that handles their TRICARE program, Wisconsin Physicians Service, (866) 773-0404. The TRICARE for Life website has details on costs and payments made by Medicare, TRICARE, and the TFL beneficiaries.
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