Program Integrity can assist beneficiaries with balance-billing issues

October 1, 2024

Balance-billing occurs when a provider bills a beneficiary the difference between the TRICARE-allowable and the billed charges for the services rendered. 

 

The Humana Military Program Integrity team can assist you if a provider is billing more than the allowed amount.  Knowing the type of provider you are seeing may help you avoid unexpected costs.


Tips for understanding balance-billing:

  • TRICARE reimbursement can only occur when services are provided by a TRICARE-authorized provider. Even though a provider may have the proper certification to practice, that does not mean that they are TRICARE-authorized or even want to become TRICARE-authorized. 
  • Network providers cannot bill you more than the TRICARE allowable charge.
  • In addition, non-network participating providers who accept assignment on the claim form cannot bill more than the TRICARE allowable charge.
  • Non-network, non-participating providers may bill you up to 15 percent above the TRICARE allowed amount and they may expect payment up front.
  • Both network and non-network providers have a responsibility to collect applicable copays, cost-shares and deductibles.
  • A provider cannot bill you for noncovered services, unless you did not inform the provider that you are a TRICARE beneficiary, or you were advised that the services are noncovered in writing prior to receiving care.
  • When seeking services from a non-participating provider, you run a higher risk of balance-billed because the provider may not be familiar with the TRICARE policies.  Signing an itemized financial agreement with this type of provider, in which you agree in advance to pay full charges for services, may result in you being held financially liable. 
  • When seeking services from a non-network provider, you should first ask if the provider is willing to file the TRICARE claim on their behalf.  If not, request the itemized information before receiving the services to ensure you have the proper documentation to file the claim to avoid delays. 

 

Find out more:

TRICARE noncovered services waiver: TRICARE noncovered services waiver (humana.com)

 

Find Humana Military Network Providers online at Find providers in the TRICARE East Region (humanamilitary.com). 

 

Report fraud and abuse through beneficiary self-service or call (800) 333-1620.

  

Genetic testing scams

Octoboer 1, 2024

Genetic testing has grown considerably in popularity over the last decade. Chances are that you know someone that has been genetically tested within the last couple of years.

 

Genetic testing can range from providing interesting facts about your family history to providing a lifesaving diagnosis. Not all genetic testing is covered by TRICARE.

 

TRICARE may cover genetic tests when they are considered proven and medically necessary for the diagnosis of a suspected illness based on the patient’s symptoms. 

 

Preauthorization is required for most genetic testing. 

 

Beware of companies that:

  • Offer testing without a treating physician order
  • Give gift cards in exchange for DNA samples
  • Order repetitive testing or testing not discussed by your healthcare provider
  • Do not provide test results
  • Waive your TRICARE copay

 

Beneficiaries are crucial partners in fighting healthcare fraud.  If you suspect fraud or abuse, please make a report through beneficiary self-service or call (800) 333-1620.

  

Red Hill fuel release public health response

September 20, 2024

In November 2021, a jet fuel spill occurred in O’ahu, Hawaii. The fuel entered the water system at Joint Base Pearl Harbor-Hickam. This event is known as the Red Hill fuel release. Impacted TRICARE beneficiaries can get medical assessments. The assessment will determine if further care is needed. If you live in the area, assessments take place at the Naval Health Clinic Hawaii’s Branch Health Clinic – Makalapa and Joint Base Pearl Harbor-Hickam. Assessments are also available for beneficiaries who live outside the area now.

 

For more information about the fuel release, symptoms and eligibility for assessments and care, please read the Frequently Asked Questions (FAQ). The Defense Health Agency (DHA) also has a Red Hill Public Health Information site with webinar recordings and details about a long-term health registry.

 

If you have symptoms, you can make an appointment for an assessment. Call (833) 415-3024, Monday-Friday, from 8 AM-4 PM. For questions, email dha.redhill@health.mil.

  

Discover more secure ways to pay your TRICARE premiums

April 19, 2024

Keeping your coverage with TRICARE is a top priority. Paying your enrollment fees or premiums with an electronic method will keep you enrolled and covered. Two methods—allotment and Electric Funds Transfer (EFT)—are the safest, no-hassle ways to pay your premium.

 

Here are your options for secure payment based on your TRICARE plan:

 

TRICARE Prime and TRICARE Select: You must pay by allotment, unless there’s no retired or retainer pay, such as for 100% disabled Veterans, un-remarried former spouses and survivors. When allotment isn’t possible, you may choose to pay through EFT or recurring credit/debit card payments.

 

TRICARE Reserve Select (TRR), TRICARE Retired Select (TRS), and TRICARE Young Adult (TYA): Choose to make EFT or recurring credit/debit card payments.

 

There are advantages of paying through allotment or EFT. You don’t have to worry about updating your information if you credit card expires or if you lose your card. You also have less risk of being disenrolled because of failing to pay. Set up allotment payments or EFT payments as your payment method today.

  

Durable Medical Equipment (DME) fraud

March 15, 2024

Durable Medical Equipment (DME) fraud is one of the most common types of healthcare fraud and abuse, a crime that involves filing false claims to make a profit. This can cost taxpayers billions of dollars.

 

TRICARE covers DME that is medically necessary and that a TRICARE-authorized provider orders for a specific use. Benefits do not include luxury, exercise, relaxation, comfort or sport items.

 

There are several ways a DME provider can defraud TRICARE, including:

  • Billing for medically unnecessary equipment or supplies 
  • Billing for equipment or supplies that are not given to the beneficiaries
  • Billing for more expensive equipment than what was provided
  • Giving illegal kickbacks or bribes for the referral of TRICARE beneficiaries
  • Ignoring patient cost-shares
  • Prescribing DME without patient interaction or only a brief telephone conversation 

 

If you suspect fraud or abuse, please make a report online or call (800) 333-1620.

  

Discover more secure ways to pay your TRICARE premiums!

March 9, 2024

Paying your premiums through allotment or Electric Funds Transfer (EFT) are the safest, no-hassle ways to stay enrolled and remain covered through TRICARE.


For TRICARE Select beneficiaries, allotment is required in all cases unless there is no retired/retainer pay (e.g., 100% disabled veterans, unremarried former spouses, survivors) available to cover monthly enrollment fees. If allotment is not feasible, you must establish payment through EFT or Recurring Credit Card (RCC) payments.

TRICARE Prime beneficiaries can choose between allotment, EFT or RCC payments. TRICARE Reserve Select (TRS), TRICARE Young Adult (TYA) and TRICARE Retired Reserve (TRR) beneficiaries can choose to make payments through an EFT or an RCC.

By choosing to pay through allotment or EFT, you don’t have to worry about updating expiration dates or lost credit card information, and you avoid the risk of disenrollment due to failure to pay!

Set up your new payment with either allotment or EFT payment today!

   

Accredo to fill specialty medications

March 8, 2024

As of March 1, 2024, Accredo now provides specialty pharmacy services to TRICARE beneficiaries who refill an eligible specialty medication with TRICARE Home Delivery.

Accredo provides specialty pharmacy services, such as scheduled medication delivery and refill reminder calls. These expanded specialty pharmacy services are given at no additional cost beyond the TRICARE cost-share.

Beneficiaries can get advice from trained staff 24/7. Specialty-trained pharmacists, nurses, patient care supporters and other professionals make up the care team. They help beneficiaries understand their medication therapy.
Reminder about freestanding emergency room visits

October 13, 2023

 

When seeking emergent care, you are encouraged to seek care from the closest emergency provider. If you receive care from a provider in a freestanding emergency room that is not affiliated to a hospital, TRICARE will not make reimbursement for care rendered because it does not recognize the facility as a certified provider. Certified providers can file claims and receive payment for TRICARE services and have met TRICARE licensing and certification requirements.

 

If you receive care from a freestanding emergency room that is not affiliated to a hospital, you will be responsible all applicable costs.

Non-covered services waiver information

August 24, 2023

 

It is important to understand both your responsibility as a TRICARE beneficiary, as well as your provider’s responsibility when it comes to non-covered services.

 

Beneficiary’s responsibility:

 

Provider’s responsibilities:

  • Verify if a service is covered or non-covered before rendering services to a TRICARE beneficiary.  
  • Must have the patient sign the non-covered services waiver if a network provider renders a non-covered service to a TRICARE beneficiary.  
  • A non-network provider is not required to use the official TRICARE waiver; however, they must have the patient sign a waiver that is equivalent to a TRICARE non-covered services waiver.

 

Information about the waiver:

  • This waiver confirms that the beneficiary is aware that the service is not covered and that the beneficiary is financially responsible for the rendered service.  
  • If there is no signed waiver, the provider cannot hold the beneficiary financially responsible for the claim. 
  • The use of this waiver protects the provider from payment misunderstandings with a patient and/or having to cover the cost of non-covered services rendered to a TRICARE patient. 
  • Non-covered services list (the list is not all inclusive). 
May is Mental Health Awareness Month

May 1, 2023

 

Supporting the health and well-being of our military service members and their families is the most important thing we do. May is Mental Health Awareness Month, and DoD is fighting the stigma with seeking help. At Humana Military, we offer you behavioral healthcare (in-person and via telemedicine) as well as webinars and community groups—we want you to get the care and support you need when and where it’s convenient for you.

 

Referrals are required for Active Duty Service Members (ADSM).

Pharmacy network changes

December 20, 2022

 

Retail pharmacies

On Jan. 1, 2023, the Kroger family of pharmacies will leave the TRICARE network. This includes pharmacies at Kroger, Harris Teeter, Fred Meyer, Smith’s Food and Drug and King Soopers. After this date, if you fill a prescription at a Kroger family pharmacy, you will have to pay the full price*.

 

You still have a large network of retail pharmacies near where you live, and you can continue to use TRICARE Home Delivery and military pharmacies. 

 

Here are ways to transfer your drug prescriptions (for non-specialty medications):

 

  • Call the new pharmacy to transfer the prescription, or ask your doctor to call.
  • Bring the prescription label to your new pharmacy.
  • Ask your doctor to send a prescription electronically to TRICARE Pharmacy Home Delivery if your drug is available.
  • Move eligible prescriptions.
  • Call (877) 363-1303, and choose option 3.

 

*You may file a claim for reimbursement to get the retail non-network pharmacy co-payments.

 

Specialty drugs

On Jan. 1, 2023, the TRICARE retail pharmacy network for specialty drugs will change to Accredo. In order to pay only network copays, you must move the prescription to a network pharmacy on or before this date. Here are ways to transfer your specialty prescriptions:

 

  • Accredo Specialty Pharmacy
  • Another network pharmacy
  • TRICARE Pharmacy Home Delivery or
  • A military pharmacy

 

Here are some tips for filling your specialty medication prescription:

  • Check with your local military pharmacy to see if they stock the drug and if so, how to transfer your prescription
  • Find participating pharmacies through the TRICARE formulary search tool
  • Call Accredo at (877) 882-3324
  • Home infusion medications can be dispensed and will be covered by the pharmacies listed above and home infusion providers.
  • Beneficiaries prescribed compound medications will need to fill their prescriptions at a network pharmacy. If a beneficiary is unable to locate a pharmacy or needs additional support, please email Express Scripts

 

Update to Phillips Respironics recall

December 20, 2021

 

The FDA has released an update regarding the recall of certain Philips Respironics ventilator devices and Positive Airway Pressure (PAP) devices. In November 2021, FDA posted an announcement related to a potential issue with the foam used for repair and replacement devices.
 

The FDA has requested that Philips Respironics retain an independent laboratory to perform additional testing to determine what, if any, potential safety risks may be posed to patients by the silicone-based foam. While this independent testing is performed, the FDA does not recommend that patients who have participated in the repair and replace program discontinue use of their product. The FDA has reached this determination based on an overall benefit-risk assessment. At this time, the agency has determined that discontinuing use of one of these devices may be more harmful to a patient’s health and quality of life. The results from the independent testing are needed to determine if the silicone-based foam used in the repaired devices does in fact present any risks to patients, and the FDA will communicate those results to the public as soon as they are available

COVID-19 booster vaccine for immunocompromised

November 9, 2021

According to the Centers for Disease Control (CDC), people who are considered immunocompromised may not build the same amount of immunity to the two-dose COVID-19 vaccine series compared to those who are not immunocompromised. Therefore, it is important for anyone who is immunocompromised to receive his or her third dose of the vaccine, 28 days after your second dose, beginning this fall.
 

See vaccine recommendations for the immunocompromised or more information.
 

Anyone who has not received the COVID-19 vaccine should do so as soon as possible.
 

Find out more: