FALLS CHURCH, Va. –
Do you or your spouse have health coverage through an employer? Or maybe you’ve been shopping for additional coverage due to a change in your health needs.
TRICARE may not be the only health coverage you have. If you have health insurance through an employer, a spouse’s plan, or a private insurer, it’s considered other health insurance.
OHI can affect how TRICARE processes your claim. TRICARE and OHI work together to help cover your health care and services, as described in Chapter 4, Section 1 of the TRICARE Reimbursement Manual.
Understanding how TRICARE coordinates with OHI can help ensure your claims are processed correctly, helping to avoid unexpected costs.
Which insurance pays first?
In most cases, TRICARE pays
after your OHI has processed your
claim. Here’s how it works:
- Employer-sponsored and private insurance: OHI pays first. After your OHI processes the claim, TRICARE may cover some—or all—of the balance.
- Medicare, OHI, and TRICARE For Life:
- Whether Medicare or your OHI pays first depends on several factors: whether your OHI is based on current or former employment (and the number of employees), and if you have end-stage renal disease. Medicare only coordinates with one other health plan.
- If OHI pays after Medicare, and there is a remaining balance, you’re responsible for filing a claim with TRICARE.
- TRICARE pays last, after Medicare and OHI, as described in the TRICARE For Life Handbook.
- If you have Medicare and have questions about who pays first, or if your coverage changes, call Medicare’s Benefits Coordination and Recovery Center at 855-798-2627 (TTY: 855-797-2627) .
- Travel insurance: If you buy a temporary plan for travel, TRICARE will process your claims only after your travel insurance.
There are a few times when TRICARE pays first. This includes when you have:
- Medicaid
- TRICARE supplemental plans
- Eligibility for state victims of crime compensation programs
- Other federal government programs identified by the Defense Health Agency
If TRICARE mistakenly pays first when it shouldn’t, it may take back the payment and reprocess your claim after your OHI has processed it.
OHI for active duty service members
Active duty service members can use OHI under
certain circumstances. If you use OHI, keep the following in mind:
- You’re responsible for all costs.
- TRICARE won’t be second payer. There’s no coordination of benefits with your OHI and TRICARE.
- You must disclose your military status to your OHI to avoid denials or recoupments.
- If you get care from a civilian provider, you must comply with service regulations.
- Unauthorized care may affect your fitness for duty status.
What you need to do
To avoid claims processing delays, let your TRICARE contractor and care providers know you have OHI. You can
report your OHI by:
If your OHI coverage changes, notify your TRICARE contractor right away. Losing OHI is a Qualifying Life Event, so you’ll have 90 days to make changes to your plan.
Using OHI with TRICARE pharmacy and dental coverage
Stay informed and notify TRICARE
Properly coordinating your OHI with TRICARE ensures you maximize your benefits and avoid delays in claims processing. If you have OHI:
- Tell your TRICARE contractor and healthcare providers about your OHI.
- Make sure your claims are submitted in the correct order.
- Notify TRICARE if your OHI coverage changes.
Unlock your health by taking these simple steps today. When everyone is informed and working together, you’ll ensure that your health coverage is maximized. For more details, visit Using Other Health Insurance.