Program Integrity can assist beneficiaries with balance-billing issues

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

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

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

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

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.