FALLS CHURCH, Va.  –   When you receive a service, medication, or treatment as part of your TRICARE benefit, filing a claim is the way your provider gets reimbursed for their services. If you pay for services up front, filing a claim is how you get reimbursed. Read more to learn about when you need to file your own claim, how to view claim information, and how you can appeal a denied claim.

“Filing your own claims can sound intimidating if you’ve never done it before,” said Jennifer N. McFarland, senior program analyst, Claims and Customer Service Section, TRICARE Health Plan, at the Defense Health Agency. “But by following a few simple steps, you can get reimbursed for TRICARE-covered medical expenses you needed to pay up front.”

Claims

Who files TRICARE claims?

Providers who are part of your regional contractor’s network must file your claims for you. Seeing network providers is the easiest and most cost-effective way to get care.

There are two types of non-network providers: participating and nonparticipating. If you see a non-network nonparticipating provider, they normally won’t file your claims for you.

You’ll also need to file your own claims if you get civilian care overseas, or if you see a provider who opts out of Medicare when you have TRICARE For Life. The TRICARE regional contractors don’t process claims for TFL beneficiaries. Medicare participating and non-participating providers must file claims with Medicare. Medicare will process and pay their portion of the claim, then forward it to the TFL contractor, WPS Government Services.

Filing your own claims

If you file your own claims, be sure to submit them as soon as possible.

• In the U.S. and U.S. territories, you must file your claims within one year of service.
• In all other overseas areas, you must file your claims within three years of service.

There are a few other tips to keep in mind if you need to file your own claims:

• File each claim separately. Submitting more than one claim in a single submission can lead to confusion.
• If you have other health insurance, be sure to file with them first.
• Make sure you write your sponsor’s DOD ID number or DOD Benefits Number on the bill if it isn’t there already.
• If your bill has the name of multiple providers in the practice, circle the name of the provider who treated you.

For more information about filing your own medical claims, visit Medical Claims and Filing Tips.

What happens to a claim once it’s filed?

Once a claim is filed, your regional contractor will:

1. Review it for accuracy and assign it a unique claim number
2. Confirm you’re eligible for the TRICARE benefit by checking the Defense Eligibility Enrollment Reporting System
3. Process the claim according to the benefits associated with your health plan
4. Verify if the provider is network or non-network. This determines the reimbursement rate.
5. Conduct a medical necessity review if applicable
6. Issue payment and communicate the results in an explanation of benefits
7. Submit a record of the claim to the Defense Health Agency

Note: If it looks like someone else may be responsible for your injury, your regional contractor will send you a Statement of Personal Injury-Possible Third Party Liability (DD Form 2527). You must complete this form within 35 days or the contractor may deny your claim.

Tracking claims

Once a claim is filed with your regional contractor, you can check the status of your claim online. Register on your claims processor’s site:

• East Region
• West Region
• Overseas Region 
• TRICARE For Life (U.S. and U.S. territories only)

Pharmacy claims

You’ll need to file your own claims if you use a non-network pharmacy or if you use OHI. Learn more at Pharmacy Claims.

Dental claims

Do you have the TRICARE Dental Program? If you see a network dentist, you shouldn’t have to file claims. However, if you need to file a dental claim, you can learn more at Dental Claims.

Appeals

Medical appeals

If you disagree with a claim decision, you can file an appeal. There are two types of medical appeals: factual and medical necessity.

• You can file a factual appeal with your regional contractor if TRICARE didn’t pay for covered services you received, or if TRICARE stopped paying for services that were previously authorized.
• You can file a medical necessity appeal if TRICARE denied pre-authorization due to finding the service not medically necessary.

If you have TFL, you’ll file an appeal with Medicare first if the service is covered by Medicare. If the service is only a TRICARE-covered benefit, you’ll file an appeal with TRICARE first.

Pharmacy appeals

Pharmacy appeals have a separate process. You can file a pharmacy appeal if Express Scripts denied your claim, your request for medical necessity, or your request for prior authorization.

Dental appeals

If you’re enrolled in the TDP and disagree with a claims decision, you can file an appeal with United Concordia, as described in the TRICARE Dental Program Handbook.

Learn more

To learn more about filing your own claims, read “TRICARE How-To: Filing Claims and Reimbursements.” If you live overseas, check out “How To File Your TRICARE Claims Overseas.”

Would you like the latest TRICARE news sent to you by email? Visit TRICARE Subscriptions to get benefit updates, news, and more.