Balance billing is the practice of a provider billing a beneficiary the difference between the TRICARE allowed amount and the billed charges on a claim. Participating providers and network providers may not collect from all sources an amount which exceeds the TRICARE allowed amount. Non-participating providers may not collect an amount which exceeds the balance billing limit - 115% of the allowed charge. If the billed charge is less than the balance billing limit, then the billed charge is the maximum amount that can be collected by the non-participating provider.
A network provider may not require payment from a beneficiary for any excluded or excludable services that the beneficiary received from the provider, except as follows:
If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided,
If the beneficiary was informed that the services were excluded or excludable and he/she agreed in advance to pay for the services, the provider may bill the beneficiary.
An agreement to pay must be evidenced by written records - specifically, the completion by the patient of a Non-Covered Services Waiver Form. General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or excludable. Use the link below to access a copy of the Non-Covered Services Waiver Form
POS is an option that allows the TRICARE Prime beneficiary to obtain medically necessary services, inside or outside of the network, from someone other than his/her primary care manager, without first obtaining a referral or authorization, with the exception of behavioral health services which do require a preauthorization. Utilizing the POS option results in a deductible and greater out-of-pocket expenses for the beneficiary.
Providers can refer a beneficiary for case management by completing a case management referral form - which can be accessed directly by clicking on the link below. The form should be faxed to the appropriate Humana Military market office. The fax numbers for the three market offices (Southeast, GulfSouth and Southwest) are located on the form
An MTF provider who has enrolled in MyHMHS for Providers can refer a beneficiary to the Heart Failure, Asthma or Diabetes Disease Management Programs by going to www.humana-military.com and selecting "MyHMHS for Providers". From there, the MTF provider can complete the form and submit it. Non-MTF providers or MTF providers not enrolled in MyHMHS for Providers can refer a beneficiary by calling our toll-free disease management number: 1-800-881-9227.
DEERS is the Defense Enrollment Eligibility Reporting System. DEERS registration verifies the beneficiary's eligibility to receive TRICARE benefits. If the beneficiary is not properly registered in DEERS, referrals and authorizations cannot be processed.
A newborn infant is covered as a TRICARE beneficiary in DEERS for the first 60 days after birth - as long as one additional family member is enrolled in TRICARE Prime or TRICARE Prime Remote. After the initial 60 days, any claim submitted for a newborn will process as TRICARE Standard until the infant is enrolled in DEERS and TRICARE Prime or the infant's TRICARE Standard eligibility ends. Eligibility for TRICARE Standard benefits ends 365 days after birth for any newborn infant who is not enrolled in DEERS.
Following the loss of entitlement to military medical benefits, beneficiaries may apply for temporary, transitional medical coverage under the Continuation of Health Care Benefits Program (CHCBP), a premium-based healthcare program providing medical coverage for former military beneficiaries. CHCBP is similar to, but not part of, TRICARE. The CHCBP option began on October 1st, 1994 and it extends healthcare coverage to the following individuals when they lose military benefits:
The Service Member
Certain unremarried former spouses
children who lose military coverage due to age or marriage
Medicare is the primary payor for the beneficiary who is eligible for Medicare Part A based on age, disability or end stage renal disease and is enrolled in Medicare Part B (active duty family members entitled to Medicare aren't required to purchase Part B until their active duty sponsor retires).
Dual-eligibles are those individuals who are enrolled in TRICARE and are:
Medicare-entitled uniformed services members
Medicare-entitled retired guard members and reservists,
Medicare-entiteld family members and widows/widowers, and
Medicare-entitled unremarried former spouses who meet TRICARE eligibility requirements
