You or your provider should send your claim form(s) to PGBA as soon as possible after you receive care. The sooner PGBA receives the claim form and documenting paperwork, the sooner you or your provider will be paid. PGBA must receive claims within one year of the date the service was rendered. In the case of inpatient care, PGBA must receive the claim within one year of the date of discharge.
No. The $12 copayment for outpatient services is required for Prime retirees and their family members. Outpatient services include provider office visits, family health services, home health care and non-preventive lab and x-ray services. This is a non-reimbursable cost associated with the Prime program.
When a TRICARE claim is filed on your behalf for medical or behavioral health services, an Explanation of Benefits (EOB) is generated. The EOB details the costs associated with the claim, the portion that TRICARE paid and, where applicable, the portion that you, the beneficiary, owe. In the interest of reducing paperwork and costs, you will only receive a copy of your EOB if you have a financial responsibility above the copayment amount for a particular claim. The link below takes you to a picture of a South Region EOB. Clicking on "Next Page" in that image will take you to a detailed explanation of "How to Read Your EOB".
You can always request a copy of your EOBs either over the phone or over the Internet. To request that an EOB be mailed to you, call Humana Military's claims processor, PGBA, LLC, at 1-800-403-3950. When you call, you'll need your sponsor's information, your provider's information and the date of the service. You can also view your EOB on the Internet by logging into the members' section at www.myTRICARE.com.
The claims processor for the South Region is Palmetto Government Benefits Administrators (PGBA). The addresses below will help you determine where to send in your claim.
Resource Sharing Claims - P. O. Box 7033, Camden, SC 29020-7033
Mental Health Claims - P. O. Box 7034, Camden, SC 29020-7034
Extended Care Health Option (ECHO) - P. O. Box 7036, Camden, SC 29020-7036
Adjunctive Dental Care - P. O. Box 7037, Camden, SC 29020-7037
All Other Claims - P. O. Box 7031, Camden, SC 29020-7031
If you have a dispute with certain decisions made by PGBA (Palmetto Government Benefits Administrators) or TMA (TRICARE Management Activity) you have the right to ask PGBA or TMA to take another look or to get another opinion on the decision. The appeals process varies, depending on whether the denial of benefits involves a medical necessity determination (whether the care was medically necessary) a factual issue (coverage issues, hospice care, foreign claims, etc.) or a provider sanction (termination of providers because of fraud, abuse or conflict of interest).
You can't appeal the amount that PGBA determines to be the allowable charge for a particular medical service. You can ask the TRICARE contractor to review the amount of the allowable charge.
You can't appeal the decision by TMA or PGBA to ask you for more information before action on your claim or other request.
You can't appeal decisions relating to your eligibility for TRICARE. While this issue affects your use of TRICARE, the uniformed services determine if you or your family members are eligible for TRICARE and issue ID cards. Eligibility issues must be appealed through the appropriate military service involved.
Keep a copy of the claim form and all other original documents that are sent to TRICARE. In case you have questions about your claim or you think there has been an error in processing your claim you will need to have your own copies to support your claim for reimbursement.
TRICARE network providers will file your claims for you and only collect any required cost shares or co-pays upfront. TRICARE authorized providers are classified as participating or nonparticipating providers. Participating providers function as network providers when it comes to fees and filing claims. Nonparticipating providers may ask for payment at the time of your visit. If that happens, you’ll need to pay at the time of service and then file a claim to be reimbursed. To be reimbursed, fill out DD Form 2642 and file it with Humana Military’s claims processor, PGBA. PGBA can be contacted by calling 1-800-403-3950.
