FALLS CHURCH, Va.  –   Your TRICARE explanation of benefits is an essential tool for understanding your health claims. An EOB is a statement from your health plan that details what action TRICARE has taken on your claims.

An EOB isn’t a doctor’s bill. But it does tell you what TRICARE has paid—or not paid—on your claim and how much you owe to your provider for your share of the costs, as described in Chapter 8, Section 8 of the TRICARE Operations Manual.

Take a moment to understand your EOB, what it means, and what may be required on your part.

When will I get an EOB?

You’ll typically receive an EOB after TRICARE processes a claim. TRICARE processes a claim when you get civilian health care or dental care or fill a prescription. If you live:

• In the U.S.: You don’t need to file your own claims if you use a network provider. If you see a non-network provider, be prepared to file your own claim.
• Overseas: You may need to file your own claims (depending on your TRICARE health plan).

If you’ve had multiple claims in the same month, TRICARE might send you a consolidated statement.

You should receive your EOB within six weeks of getting a service by mail or secure message. If you don’t, contact your provider to ensure that the claim processed correctly.

What information is on my EOB?

The information on your EOB will be different depending on whether it’s a medical, pharmacy, or dental EOB.

Medical EOB

You’ll get a medical EOB when you get healthcare services with TRICARE.

Medical EOBs look slightly different across TRICARE regions, but they all have the same information about services you received. Here are some key sections you should pay attention to when reviewing a medical EOB.

Information about the claim:

• Claims Processor and Regional Contractor: The claims processor and regional contractor that handled your claim.
• Date of Notice: The date the claims processor prepared your EOB. (If you need to appeal your claim, you must do so within 90 days of this date.)
• Patient Name: The person the provider saw or treated
• Provider: The provider (individual or facility) who saw or treated the patient
• Date of Service: The date or dates the service was provided
• Claim Number: A unique number for tracking purposes. (Take note of this if you have a question about your claim.)
• Service Provided: Describes the service received. It lists specific procedure codes.

Information about costs:

• Total Patient Responsibility: The amount you properly owe the provider
• Benefit Period Summary: The amount the claims processor applied to your family’s deductibles and catastrophic cap. (Note: The deductible and catastrophic cap are reset every year.)
• Amount Other Insurance Paid: The amount your other health insurance paid, if you have OHI
• Amount You Paid: The amount you paid the provider, as noted on the claim
• Amount Your Provider May Collect from You: The amount you owe (deductible, copayment, cost-share)
• Amount TRICARE Paid Your Provider
• Amount TRICARE Paid You
• Your Provider Charged: The amount the provider billed TRICARE for a particular service
  • Allowed Amount: The amount TRICARE allows based on the date and location of service and provider status (network, non-network, or non-authorized)
  • Amount Not Covered: The amount TRICARE doesn’t cover
  • Copayment and Cost-Share: The amount you owe

Checking all these details will help you learn which services are included in the EOB and what your remaining costs may be.

Pharmacy EOB

Express Scripts administers the TRICARE Pharmacy Program benefit.

You’ll get an EOB after you fill prescriptions. Reviewing your pharmacy EOB can help you learn how your costs may differ when you use different pharmacy options.

If a pharmacy claim is denied, you’ll receive an explanation why, as detailed in the TRICARE Pharmacy Program Handbook.

Dental EOB

Are you enrolled in the TRICARE Dental Program? United Concordia administers your TRICARE dental benefit. If you get dental services, you’ll get an EOB from United Concordia.

Many of the sections are the same as a medical EOB. But take note of:

• ICN (Internal Control Number): A unique number United Concordia uses to identify the claim.
• Allowance: The amount United Concordia allows for the service. (This will differ based on the provider’s network status.)
• Amount Paid: The amount paid by United Concordia.
• Amount Not Paid: The portion of the bill that United Concordia didn’t pay. You may be responsible for the amounts listed in this section, marked with an asterisk.

Does TRICARE For Life have EOBs?

TRICARE For Life produces monthly summary EOBs, rather than immediately after a visit. This means several services may be included on one EOB.

If you want to receive an EOB each time you see a provider, you’ll need to log in to www.TRICARE4u.com and “opt in.” You’ll then be able to view individual EOBs for each service online.

Note: TFL EOBs are separate from Medicare Summary Notices you’ll receive for Medicare Part A and Part B claims. If you have Medicare Part C or Part D, your plan will mail you an EOB each month you visit a healthcare provider, fill a prescription, or file a claim. Learn more about checking your claim status with Medicare.

What should I do with my EOB?

While reviewing your EOB:

• Check for accuracy: Ensure that all listed services match what you received. If you have a question, or if you believe you’ve found an error related to the services you received, you should contact the regional contractor or claims processor listed on the EOB.
• Keep it for your records: Keep your EOBs with your health records for future reference.

Do you disagree with a decision listed on your EOB? You can file an appeal of certain decisions within 90 days of the “Date of Notice” at the top right.

Can I access my EOBs online?

To streamline your healthcare management, you can sign up to receive your EOBs online. You can access your statements securely through the contractor’s website:

• East Region
• West Region
• Overseas
• TRICARE For Life
• TRICARE Pharmacy Program
• TRICARE Dental Program

Signing up for online EOBs is a safe way to ensure timely, 24/7 access to your claims information. You can download copies for your records.

Reviewing your EOB helps you to stay informed about your care costs. Unlock your health and review your latest EOB today.

Do you have questions after reviewing your EOB? Reach out to your claims processor or regional contractor.