TRICARE and Other Insurance: Primary or Secondary Payer

Introduction

• Instructor: Oliver
• Topic: Review of TRICARE as primary or secondary payer alongside other insurances

Key Concepts

Other Health Insurance (OHI)

• Any insurance in addition to TRICARE is termed as Other Health Insurance (OHI) by TRICARE.
• Examples include:
  • Medicare plans
  • Employer-sponsored health insurance
  • Various commercial insurances (e.g., Cigna, Prudential, Blue Cross Blue Shield)
• Note: TRICARE supplements are NOT considered OHI.

Order of Payment

• OHI as Primary Insurance:
  • Pays claims before TRICARE.
  • Affects:
    • Retired TRICARE beneficiaries using Medicare
    • Spouses of active duty members with employer coverage
• TRICARE as Primary for Active Duty:
  • Active duty members only have TRICARE.

Coordination of Benefits

• Important to update OHI with healthcare providers to prevent claim delays/denials.
• If OHI is primary:
  • Health care claims are processed by OHI first, then TRICARE.
  • Exceptions: Medicare, Medicaid, TRICARE supplements, Indian Health Services
• Claims Process:
  • If TRICARE gets a claim first, it denies until OHI processes it.
  • If TRICARE pays first by mistake, it reclaims payment after OHI processes.

Changes in Insurance

• Without OHI, TRICARE becomes primary.
• With TRICARE for Life, TRICARE becomes secondary.
• Note for Physicians: Stay informed about changes in patient's insurance status.

Prescription Drug Coverage

• With OHI covering pharmacy benefits:
  • OHI pays first, TRICARE pays second.
  • Savings possible at TRICARE network pharmacies covered by OHI.

Conclusion

• Video aimed to provide insights on TRICARE and OHI dynamics.
• End Note: Keep OHI updated with healthcare providers to ensure smooth claim processes.

Thank you for joining the session!