Payment guidelines

If TRICARE is the secondary payer, submit the claim to the primary payer first. If the claim processor’s records indicate that the beneficiary has one or more primary insurance policies, submit EOB information from other insurers along with the TRICARE claim.

Humana Military will coordinate benefits when a claim has all necessary information (e.g., billed charges, beneficiary’s copay and OHI payment). In order for Humana Military to coordinate benefits, the EOB must reflect the patient’s liability (copay and/or cost-share), the original billed amount, the allowed amount and/or any discounts.

If the EOB indicates that a primary carrier has denied a claim due to failure to follow plan guidelines or use network providers, TRICARE will also deny the claim.

TRICARE does not always pay the beneficiary’s copay or the balance remaining after the OHI payment. However, the beneficiary liability is usually eliminated. The beneficiary should not be charged the cost-share when the TRICARE EOB shows no patient responsibility.

Payment calculations differ by provider status as detailed below. With TRICARE network providers and non-network providers that accept TRICARE assignment, TRICARE pays the lesser of:

  • The billed amount minus the OHI payment
  • The amount TRICARE would have paid without OHI
  • The beneficiary’s liability (OHI copay, cost-share, deductible, etc.)

With non-network providers that do not accept TRICARE assignment, providers may only bill the beneficiary up to 115 percent of the TRICARE allowable charge. If the OHI paid more than 115 percent of the allowed amount, then no TRICARE payment is authorized, the charge is considered paid in full and the provider may not bill the beneficiary. If the service is considered noncovered by TRICARE, the beneficiary may be liable for these charges.

With all other providers, TRICARE pays the lesser of:

  • 115 percent of the allowed amount minus the OHI payment
  • The amount TRICARE would have paid without OHI
  • The beneficiary’s liability (OHI copay, cost-share, deductible, etc.)

When working with OHI, all TRICARE providers should keep in mind:

  • TRICARE will not pay more as a secondary payer than it would as a primary payer.
  • Point-Of-Service (POS) cost-sharing and deductible amounts do not apply if a TRICARE Prime beneficiary has OHI. However, the beneficiary must have prior authorization for certain covered services, regardless of whether he or she has OHI.

Send all requests to:

TRICARE East Region claims
P.O. Box 8923
Madison, WI 53707-8923

Reimbursement rates and methodologies are subject to change per Department of Defense (DoD) guidelines. For more information, refer to the TRICARE Reimbursement Manual

TRICARE claims information