ENROLLMENT
Can we change the PCM for someone on TRICARE plus?
Each military hospital or clinic leader decides if TRICARE plus is available. Callers would need to contact their local MTF to see if they offered the program or to make changes.
What is United Concordia
The supplemental dental program for reserve guard families and active-duty service member families.
Will TRICARE cover glaucoma exams without a referral/authorization for prime beneficiaries?
TRICARE does cover eye exams and other specialized services to diagnose or treat eye conditions. Prime plan requires your PCM to work with your regional contractor for referrals and authorizations.
How do we know what the patients out of pocket costs will be for a service?
You would need to research the copay and cost shares listed for their plan in tricare.mil
Can we assist a provider who does not have a profile in Salesforce?
Yes. You would use the KB resource Verifying Callers to assist with a specific beneficiary patient question
why would a sponsor's plan change from TPR to Prime?
A sponsor's enrollment is based on their active-duty station location. We would use the MTF tool to verify what they need assigned to them.
How many eye exams can a TRS beneficiary have?
When activated, the caller is eligible for the same benefits as active-duty service members and family members. Deactivated reservists and families are eligible for one routine eye exam per year.
Is a referral needed for urgent care when the caller is active-duty sponsor?
ADSM should seek care at a military hospital or clinic when and where available. They can also contact the MHS Nurse advice line for assistance.
A provider calls to verify status of 20 claims. How would you assist them?
We can only assist the provider with a maximum of 5 claims per call. Directing the provider to our self-service options would be the best utilization of their time and should reserve on call assistance for claims issues that they cannot get from these resources.
How does a provider contract as a Network provider with TRICARE?
The provider would visit our website tricare.triwest.com and complete the provider contract request form.
How do we enroll dependent parents?
If you're on active duty for more than 30 days or you're retired, you can apply for your dependent parents and parents-in-law to get care in MTF or TRICARE plus (plus programs are handled directly with the base).
Can a beneficiary get a portable CPAP machine?
TRICARE may cover a portable CPAP machine. You must be an active-duty service member and have a referral. The referral needs to include your diagnosis of obstructive sleep apnea, you travel on official business at least three days per month or your being deployed, and you aren't retiring or separating from the military within the year.
Does a beneficiary under select require a referral for any service?
No. Referrals aren't required for most primary and specialty appointments. You may need a pre-authorization from your regional contractor for some services.
A prime beneficiary calls and is confused about seeing a very high patient responsibility on a claim. How would you verify what is going on with the claim?
Agents should verify the beneficiary's enrollment during the date of service and review the codes billed. If the beneficiary is enrolled during the period of service and the codes required a referral, we should review CareRadius. Often times we will discover that the caller had an enrollment issue or their care was not approved prior to receiving it causing POS or claims denial.
Hey. Did you want some more points?
Do we assign PCM for USFHP?
USFHP is managed by a hospital network within a beneficiaries PSA. They would need to contact that hospital for all their enrollment needs.
What is the most important thing you could do to assist your callers with understanding their TRICARE benefits?
Direct them to tricare.mil so they can review their benefits themselves
Can we change the servicing provider on a referral/authorization if it is showing an MTF hospital or clinic?
No. The right of first refusal process allows the MTF to provide specialty care to those with TRICARE prime. Reversal is allowed for very few reasons such as continuity of care or special circumstances that prevent you from using a military clinic or hospital. If you choose a provider before the right of first refusal decision, and the MTF can provide the services, you must go to the military facility instead.
What can we do to assist a caller that has claims denied for OHI, but there is no OHI listed in Salesforce?
We would direct the caller to submit the OHIQ. A case can be completed by a claims support agent if the caller has submitted a questionnaire more than 30 days ago.
Can we enroll a caller into a prime/select plan when they are already enrolled in USFHP? This caller does not have a QLE and it is not open season.
Yes. USFHP is not considered a different plan type and is just administered differently than regular prime/select. Our callers do not need a QLE or open season to change how their plan is administered
A sponsor cannot verify their newborn child's last 4 digits of SSN, their DBN, or the DOD ID. They can verify the address. Can we assist with a PCM change?
No. We must verify the callers full name, the dependents full name, and 2 of the following for the dependent: last 4 of SSN, DOB, DOD, or DBN.
Would a beneficiary need to meet their deductible before meeting their catastrophic cap while on TRICARE prime?
TRICARE prime does not have a deductible. They can use point of service benefits in cases they wish to choose the care they receive, but that does not apply to the catastrophic cap.
What are the processing times of a referral and how can I find it?
A routine referral request is processed within 1-2 business days of receiving the request.
Can a select beneficiary get care from a non-network provider that is nonparticipating with TRICARE?
Yes. A select beneficiary can choose to see a non-network provider based on their plan benefits. Nonparticipating provider don't accept the TRICARE allowable charge as payment in full. They won't normally file claims with TRICARE. You probably have to pay the amount in full to the provider and file the claim with TRICARE for reimbursement (minus your cost-share). The has the legal right to charge up to 15% more than the TRICARE allowable charge. Any charge above the TMAC are your responsibility and won't be reimbursed.
What is the processing time of an authorization?
A routine authorization is processed within 2-5 business days of receiving the request from the provider and all required clinical documentation.