Jeffrey Wade
If you have health insurance other than TRICARE, it is considered other health insurance or OHI. It is important to keep your OHI information updated and inform your TRICARE contractors and doctors when you gain or lose other health insurance. If you lose your OHI, TRICARE becomes your primary payer, and if you have TRICARE for Life, it becomes the second payer after Medicare. TRICARE requires coordination of benefits with OHI coverage, and the calculation of the TRICARE payment is based on the provider's status.
| Characteristics | Values |
|---|---|
| What is OHI? | Any health insurance other than TRICARE is called "other health insurance" or OHI. |
| When to update OHI information | When your OHI changes, or when you lose or gain OHI. Losing or gaining OHI is considered a qualifying life event (QLE). |
| TRICARE as primary payer | If you lose your OHI, TRICARE becomes your primary payer. If you have TRICARE for Life, TRICARE becomes the second payer after Medicare. |
| TRICARE claim denial | TRICARE will deny your claim if it gets your claim before your OHI processes it. TRICARE will also deny your claim if your OHI denies it for failure to follow their rules. |
| TRICARE payment calculation | TRICARE does not always pay your OHI copayment or the balance left over after the OHI payment. The TRICARE payment calculation is based on the provider's status. |
| Non-network providers | Non-network providers may only bill the beneficiary up to 115% of the TRICARE-allowed amount. If the OHI paid more than this amount, no TRICARE payment is authorized. |
| TRICARE claim filing | In most cases, your provider will file your medical claims for you. Sometimes, you'll need to file your own claims by sending your claim form to TRICARE as soon as possible after you receive care. |
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What You'll Learn
Informing your doctor and contractor
If you have health insurance other than TRICARE, it is referred to as "other health insurance" or OHI. This could be through your employer, your spouse's employer, or a private insurance program. It is important to keep your OHI information updated, and to inform your TRICARE contractors and doctors of any changes. If you gain or lose OHI, this is considered a qualifying life event (QLE).
If you gain OHI, you must inform your doctor and contractor by completing and returning a form. Failure to do so may result in TRICARE denying your claims. If TRICARE pays first and then discovers you had OHI, they will take back any payments made and will only reprocess your claim after your OHI provider has paid.
If you lose your OHI, TRICARE becomes your primary payer. If you have TRICARE for Life, TRICARE becomes the second payer after Medicare.
It is important to follow the rules of your OHI for getting care and filing claims. If your OHI does not cover the entire cost, you can file a claim with TRICARE. Your OHI pays first, and TRICARE pays second. You, your doctor, your pharmacy, and your hospital must follow all the rules of your OHI. For example, if your OHI requires pre-authorization for a procedure, you must obtain this before receiving the procedure, or your claim may be denied.
If you are seeking care from a civilian provider, you must comply with Service regulations. This includes providing all medical records to your current primary care manager. You can get all your medical care, including mental health and dental care, at no cost to you through TRICARE.
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TRICARE's role as the primary payer
TRICARE is a health insurance option for those serving in the military and their families. It is important to understand how TRICARE works with other health insurance (OHI) plans, as it can act as a primary or secondary payer depending on the situation.
If you have any health insurance other than TRICARE, this is considered "other health insurance" (OHI). This could be through an employer or a private insurance program. By law, TRICARE pays after all other health insurance plans have processed their claims, except for other Federal Government Programs identified by the Director of the Defense Health Agency. This means that your OHI will be the primary payer, and you must follow their rules for getting care and filing claims. If your OHI does not cover the full cost, you can then file a claim with TRICARE.
However, if you lose your OHI, TRICARE becomes your primary payer. In this case, you must inform your doctor and TRICARE contractor by completing and returning the appropriate form. Failure to do so may result in TRICARE denying your claims.
It is important to keep your TRICARE contractors and doctors updated on any changes to your other health insurance. They can coordinate your benefits and ensure your claims are paid promptly. If TRICARE pays first and then discovers you have OHI, they will retract any payments made and will only reprocess your claim after your OHI has processed its claim.
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Claim denials
When you have other health insurance (OHI) in addition to TRICARE, TRICARE supplements or serves as secondary to the primary insurance coverage. If you don't report your OHI to TRICARE and they find out about it later, any claims previously paid by TRICARE may be denied.
TRICARE may deny a claim for several reasons. Common reasons for claim denials include:
- The service is not a TRICARE benefit.
- The claim is for a service that requires prior authorization, but you didn't get prior authorization before getting care.
- The claim is a duplicate.
- The claim is filed after the timely filing limit.
- The claim lacks required information or has incorrect information.
If a claim is denied, you will receive a letter from your regional contractor explaining the reason for the denial and providing instructions on how to appeal the decision if you disagree with the denial. You have the right to appeal any denied claim. The appeal must be submitted in writing within one year of the date of service or the date of denial.
To start the appeal process, you should first review the reason for the denial and gather any additional information or documentation that may support your case. You can then submit a written request for reconsideration to your regional contractor, clearly stating why you believe the claim should be covered. Include any supporting documentation with your appeal letter and be sure to include your name, address, phone number, and policy number on all correspondence.
If your initial appeal is denied, you have the right to request a second-level appeal. The second-level appeal is reviewed by a separate group of health care professionals and claims processors who were not involved in the initial denial decision. They will consider the information submitted with your initial appeal and make a determination. You will receive a letter explaining the decision and outlining any further appeal options if the second-level appeal is denied.
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Payment methods
If you have health insurance other than TRICARE, it is called "other health insurance" or OHI. If you have coverage in addition to TRICARE through your employer, your spouse's employer, or a private insurance program, you have OHI. It is important to keep your other health information updated and inform your TRICARE contractors and doctors when you gain, lose, or change OHI. TRICARE requires coordination of benefits with OHI coverage.
TRICARE beneficiaries are responsible for paying their providers, hospitals, suppliers, and pharmacies for the full amount of their billed charges. TRICARE will then process your claim and send you an explanation of benefits detailing what they paid. If you have OHI, your other plan pays first, and TRICARE pays second. TRICARE does not always pay your OHI copayment or the balance left over after the OHI payment, and the payment calculation is based on the provider's status. If your OHI plan denies a claim for failure to follow their rules, TRICARE may also deny your claim.
If you live in the West Region, you can set up your payment information using EFT, credit card, or debit card. For TYA, TRS, and TRR, the deadline is January 15, and for TRICARE Prime or TRICARE Select, the deadline is January 30. If you miss the deadline, you will be disenrolled back to January 1.
If you have a Staff Model HMO, Group HMO, or Other Capitated OHI Plan, you generally only receive a copayment receipt. In these cases, you submit a Beneficiary Claim Form DD2642 with a copy of your receipt, and the copayment is considered the billed amount.
TRICARE and its contractors will never call to ask for payment, your personal identifying information, or your health information. You should never share personal or financial information with someone you don’t know, and you can report any suspicious activity.
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TRICARE's coordination with OHI
TRICARE is a health insurance option for those in the military and their families. It can be used alongside other health insurance (OHI) but there are some important things to note about how TRICARE coordinates with OHI.
Firstly, TRICARE beneficiaries must keep their OHI information up to date. If you gain or lose OHI, you must inform your TRICARE contractors and doctors. If you fail to do so, TRICARE may deny your claims. If TRICARE pays first and then discovers you have OHI, they will take back any payments made and will only reprocess your claim after your OHI has processed it.
If you have TRICARE and OHI, you must follow the rules of your OHI plan for getting care and filing claims. If your OHI denies a claim, TRICARE may also deny it. This could be for a number of reasons, including failure to follow authorization requirements, using a provider outside of the OHI network, or not following prescription rules for brand name or specialty drugs. If your OHI denies a claim for services that are not deemed medically necessary, you must use all appeal rights with the OHI before TRICARE can process the claim.
If your OHI plan does not cover the entire cost, you can file a claim with TRICARE. TRICARE requires coordination of benefits with OHI coverage, but this does not include copayments or leftover balances after OHI payment. TRICARE payment calculations are based on the provider's status. If you are enrolled in a Staff Model HMO, Group HMO, or Other Capitated OHI Plan, you generally only receive a copayment receipt, and an itemized bill or Explanation of Benefits (EOB) is not available. In these cases, you must submit a Beneficiary Claim Form DD2642 with a copy of your receipt.
Active-duty service members cannot use OHI as their primary insurance. TRICARE is the primary payer and there is no coordination of benefits with other insurance carriers. All services require approval from Health Net Federal Service, LLC (HNFS). All other beneficiaries with OHI only require prior authorization for applied behaviour analysis services.
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Frequently asked questions
OHI stands for "other health insurance". It refers to any health insurance plan you might have in addition to TRICARE, such as Medicare, an employer-sponsored health insurance plan, or a private insurance program.
You must inform your TRICARE contractors and doctors when you gain OHI. You can do this by completing and returning a form. Failure to inform your doctor or contractor may result in TRICARE denying your claims.
If TRICARE pays for your care before they find out about your OHI, they will take back any payments made. They will only reprocess your claim after your OHI provider has paid.
If you lose your OHI, TRICARE becomes your primary payer. You must inform your doctor and contractor by completing and returning a form. Failure to do so may result in TRICARE denying your claims.
Yes, but only under certain circumstances and when in compliance with DoD and Service regulations. If you decide to use OHI, you are responsible for all costs. TRICARE won’t be the second payer, so there’s no coordination of benefits with your OHI and TRICARE.
