ENROLLMENT
Can T plan beneficiaries backdate coverage from BWE?
If a tree falls in a forest and there is no one there to hear it, does it make a sound?
Interesting point
Can we change a CPT code on a referral or authorization?
No. We can add codes to referral/authorization but we cannot change them (exclusions include inpatient, ACD, or behavioral health)
A beneficiary calls upset their claim denied due to OHI. When viewing the OHI on file you notice they are showing Medicaid. The caller confirms they only have Medicaid and they are concerned this is a mistake. How would you assist this caller?
It is possible that the OHI on file is causing the denial. Medicaid is an insurance TRICARE will pay primary to, and the claim should be reprocessed. A cause would need to be submitted and include a callback for further direction.
How do I get a copy of my medical records?
You can get medical records from the rendering provider of your care.
Can we enroll a sponsor's niece/nephew as a dependent?
Depends. We would be able to enroll a child in the custody of a sponsor, either by a court or recognized adoption agency, in anticipation of legal adoption.
A beneficiary calls and states they have a denial for a medication. You have asked the caller if it is an oral medication being picked up at the retail pharmacy and the caller states "yes". What should this caller do?
An appeal can be filed within 90 days of the date of decision. Best course of action is for the caller to speak with Express Scripts concerning the pharmacy benefits
A nurse from the MTF is calling and wants you to backdate a referral. Can this be done?
Yes. We can only backdate referrals upon MTF request or administrative error.
What is the most current version of the TRICARE reimbursement manual?
Change 18 (July 23, 2025)
Does TRICARE cover a hair transplant?
No. This service is an excluded service with TRICARE.
A beneficiary called and states they would like to have their 27 your old child enrolled into prime. Is this possible?
There may be exceptions for a child with a disability. The child would need to be unable to provide support for themselves, depend on the sponsor for over 50% of their support, disability occurred before turning 21 (23 if enrolled as a full-time student, and they are not married.
A beneficiary calls and states they would like to see a non-network provider for specialty care because all of our network providers in their area cannot see them for 3 weeks. There is no medical reason they need to see this specific non-network provider. It is just due to the wait time. Would this beneficiary be approved for a non-network request?
No. Our access to care standard for specialty care is 4 weeks (28 days)
If a provider's address is incorrect in CareRadius, what can you do to change the provider on an existing referral/authorization?
We can add the requesting group so the beneficiary can see any network provider with the group.
How long can it take for a check to be received?
Checks arrive about 5 business days after the claim paid date
What is the most current version of the TRICARE policy manual?
Change 42 (September 12, 2025)
Can a beneficiary perform enrollment changes on secure beneficiary portal?
No. They can view plan enrollments in the secure portal but cannot make changes. Beneficiaries can make enrollment changes in BWE on Milconnect.
A beneficiary calls and states they have been seeing a specific non-network provider for care. This is out of preference and has not been approved. With the point of service charges they have paid, they are very close to meeting the cat cap limit. Once the cap is met, will the beneficiary have to continue paying the point of service?
Yes. point of service does not apply to the catastrophic cap
Will TRICARE cover anesthesia for dental care?
TRICARE will cover institutional and anesthesia services in connection with dental treatment for patients with developmental, mental, or physical disabilities, or for pediatric patients age 5 and under.
If a claim is in process for over 30 days, what should you do?
Claims typically take 30 days to process. However, a case cannot be submitted until it is 45 days in process.
Will TRICARE cover a dental procedure instead of the dental contractor?
TRICARE may cover adjunctive dental care related to a medical injury. Examples of this include removing a tooth fragment from the tongue or cheek, getting a tooth removed to stabilize a break in jaw.
A TRS beneficiary calls during open season to enroll. When checking eligibility, you see they are locked out due to lack of payment. It is past the 90 days from last paid through date. Can we enroll the beneficiary to start care for the new year.
No. TRS members do not apply to open season. The caller would need to wait until their 1-year lockout expires or until they are deployed on active duty.
A beneficiary calls and states they have an approved referral for specialty care more than 100 miles away. Can a beneficiary be reimbursed for meals they eat while traveling?
Yes. A beneficiary can be reimbursed for meals while traveling to and from appointments. They would need to speak to the prime travel benefit office to arrange reimbursement
A provider calls and states the patient's authorization has been medically denied and they want a peer 2 peer. When reviewing the documentation history, you've noticed notes about EviCore. What would you do to assist?
We would follow the instructions in the KB Setting Up Peer to Peer. Medically denied authorizations that have been handled by Evicore must be referred back to them based on step 10 in the instructions
Can I use Home Delivery for my pharmacy prescriptions? I do have Blue Cross Blue Shield as my primary insurance.
You can't use TRICARE Pharmacy Home Delivery when you have other health insurance unless: your OHI doesn't include pharmacy benefits, the drug you need isn't covered by your OHI, or you've met the OHI benefit cap. If these requirements are met, you can fill your prescription through home delivery. You'll need to send proof from the OHI that script isn't covered, or you've met your benefit cap.
A beneficiary calls and states they want to keep their TRICARE benefits. They are 67 years old and they do not have Medicare part B. Can they keep their benefits?
It depends. If they qualify for Medicare part B, they have to be enrolled with the part A and B benefits to keep TRICARE. If the caller is not eligible for Medicare A and B, they can get a notice of disapproved claim from the Social Security office and provide that to DEERS. They would continue their coverage as Prime/Select retired.