Officials explain procedures for submitting TRICARE claims

"Well, I thought the government was supposed to take care of it."

"I just figured the doctor would send it in."

"The hospital filed the claim, but they never heard anything, so now they’re coming after me."

"I sent somebody the bills, and didn’t think any more about it. Now, the doctor has a collection agency harassing me."

"I called somebody and asked for claim forms a couple of years ago, but I never got any. Now they won’t pay anything for the care I got because they say I waited too long to file the claim."

Do any of these complaints sound familiar? They do to the people who answer the phones at TRICARE service centers around the country, or at the TRICARE Management Activity (formerly known as CHAMPUS headquarters, or more recently, the TRICARE Support Office), in Aurora, Colo.

Busy people have a lot to deal with in today’s world—and now and then, some basic bits of information tend to get lost in the shuffle. Here are a few tips that may help you use your military health care benefits more effectively, and get the government to share the cost of civilian care when it’s appropriate:

* When you get covered health care under TRICARE, somebody has to pay for it. If the government is going to pay its share of the cost of covered care, somebody has to send a claim in to the proper TRICARE contractor. It may be you. It may be the doctor or hospital. But somebody has to send in a claim, or Uncle Sam won’t know you got the care—and won’t pay any of the costs.

* Before you get medical care from a civilian source, talk to the provider of care or his/her staff, to determine who’s going to file the claim with the TRICARE contractor. If they do it, they’ll have their own forms to use (the HCFA 1500 for individual providers, or the UB-92 for hospitals and other institutional providers). If you file the claim, you’ll need the DD Form 2642 ("CHAMPUS Claim: Patient’s Request for Medical Payment").

* Of course, if you’re enrolled in TRICARE Prime, or are using TRICARE extra, and are being treated by a TRICARE network provider of care, the provider will always file claims for you. If you get non-institutional care under TRICARE Standard, your provider may or may not file claims for you.

* If you have to file a claim yourself, where do you get the DD Form 2642? TRICARE contractors have them. TRICARE service centers have them. Health benefits advisers at military medical facilities have them. If you can’t get claim forms from these sources, write to the TRICARE Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.

*If you have Internet access, you can also get the claim form on-line. Just go to the Military Health System’s (MHS) home page, at: www.ha.osd.mil; or: www.tso.osd.mil.

* When you file a claim, don’t send just the bills in. They have to be attached to a claim form. Fill out the claim form completely and accurately (it’s only a half-page long) and sign it—then attach copies of the itemized bills to the claim and send it in to your regional TRICARE contractor. You have one year from the date you received the service—or one year from your date of discharge from an inpatient facility—to get the claim to the contractor for processing.

* Be sure to keep the original—or a copy—of everything you send to the contractor, so you can re-submit the claim if it’s lost, or if parts of it are separated from each other after you mail it.

* If you send in a claim—or if your health care provider does it—and the sender hasn’t heard anything from the TRICARE contractor after about a month, then the sender needs to call the contractor’s toll-free telephone number to check on the status of the claim.

Processing might have been delayed because the claim form wasn’t filled out properly, or because needed documentation wasn’t attached. Or, the claim might have become lost somewhere along the way, and might need to be re-submitted. That’ll happen occasionally, when contractors receive and process more than 25 million claims in a year.

There are many other details you need to know about filing claims. Here are two examples:

1. When—and for what kinds of care—you need a nonavailability statement, or other prior authorization that may be necessary, from the nearest military medical facility; and

2. What additional information you must attach to a claim for prescription drugs. The best place to get this information is the "How to File a Claim" chapter in the TRICARE Standard Handbook. The latest (September 1997) edition is available from the same places you get claim forms. The handbook is also on-line, on the MHS home page, address shown above.