TRICARE and Other Health Insurance (OHI)


TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service and other programs or plans as identified by the Defense Health Agency (DHA).

If the OHI benefits are exhausted, TRICARE becomes the primary payer, and additional referral/prior authorization requirements may apply. Since OHI status can change at any time, always ask all beneficiaries about OHI, including National Guard and Reserve members and their families.

Beneficiaries may not waive benefits from their primary plan. If the primary plan provides benefits for services, a claim should be filed with the double coverage plan.

Rendering providers MUST be TRICARE-certified for TRICARE to pay up to the TRICARE Maximum Allowable Charge (TMAC) on covered services.

Submitting claims with OHI

To avoid a delay in claim payment or a recoupment when OHI is uncovered, we recommend asking beneficiaries for all forms of insurance before they are seen at your office or facility. Laws for commercial plans vary by state, so supplying us with all initial information helps to ensure correct and timely processing.

If a beneficiary’s OHI status changes, update patient billing system records to avoid delays in claim payments. The beneficiary is responsible for contacting TRICARE to add, remove or change their OHI by utilizing the TRICARE OHI Questionnaire. If a claim is processed with OHI, and the beneficiary has contacted TRICARE to remove it, the OHI will automatically be added back to the beneficiary's account and the claim will deny causing a delay in payment.

If a provider indicates that there is no OHI, but Humana Military's files indicate otherwise, a signed or verbal notice from the beneficiary will be required to inactivate the OHI record.

In some cases, the TRICARE Summary Payment Voucher/Remit will state, "Payment reduced due to OHI payment," and there may be no payment and no beneficiary liability. The TRICARE cost-share (the amount of cost-share that would have been taken in the absence of primary insurance) is indicated on the TRICARE Summary Payment Voucher/Remit only to document the amount credited to the beneficiary's catastrophic cap.

Dual eligible beneficiaries with OHI

If the beneficiary has Other Health Insurance (OHI) as well as Medicare and TRICARE, TRICARE will pay after Medicare and the OHI. Once Medicare and the OHI have processed the claim, the beneficiary should file a TRICARE claim with WPS.

Identify OHI in the claims form

  • Mark "Yes" in box 11d (CMS-1500) or FL 34 (UB-04)
  • Indicate the primary payer in box 9 (CMS-1500) or FL 50 (UB-04)
  • Indicate the amount paid by the other carrier in box 29 (CMS 1500) or FL 54 (UB-04)
  • Indicate insured's name in box 4 (CMS-1500) or FL 58 (UB-04)
  • Indicate the allowed amount of the OHI in FL 39 (UB-04) using value code 44 and entering the dollar amount

Referrals and authorizations

TRICARE beneficiaries who have OHI do not need referrals or prior authorizations for covered services except for those services listed below, which require prior authorization even when OHI coverage exists.

  • Adjunctive dental care
  • Advanced life support air ambulance in conjunction with stem cell transplantation
  • Applied Behavior Analysis (ABA)
  • Extended Care Health Option (ECHO) services
  • Home health services, including home infusion
  • Hospice
  • Laboratory Developed Tests (LDT)
  • Transplants (solid organ and stem cell, not corneal transplant)
  • Autism Care Demonstration (ACD)
  • Electroconvulsive Therapy (ECT)
  • Non-emergency admissions, to include detoxification and rehabilitation services
  • Psychoanalysis
  • Residential Treatment Centers (RTC)
  • Transcranial Magnetic Stimulation (TMS)