MOAA’s TRICARE Toolkit provides insight and tips for navigating your TRICARE benefits. Have a question or suggestion for an upcoming column? Email beninfo@moaa.org. Read other TRICARE Toolkit columns at MOAA.org/tricaretoolkit.

A change in your health care plan can sometimes lead to unexpected complications. While these issues can happen anytime, they typically arise during a transition — from active duty to reserve or retirement, from military treatment facility (MTF) care to civilian provider care, or from TRICARE to Medicare and TRICARE for Life (TFL).

While MOAA hears from our members regarding other roadblocks that arise within the military health system, the key to finding resolutions is to know,
understand, and access the resources available to help resolve your problem.

Direct Care

Members and beneficiaries receiving treatment from an MTF are receiving direct care. Military medical centers and their clinics have patient advocates to assist and support patients and families with problems associated with their care, or the medical or administration staff. Also known as patient representatives, these individuals help navigate the direct care system by providing options and assistance.

This Healthcare Resolutions program can be found on each MTF’s website.

TRICARE/Civilian Care

Non-direct care problems that arise for TRICARE (other than TFL) recipients must first be resolved at the regional contractor level.

The TRICARE East Region is managed by Humana Military (800-444-5445 or www.humanamilitary.com). TRICARE West is managed by HealthNet Federal Services (844-866-9378 or www.hnfs.com). International SOS is TRICARE’s overseas contractor; their three regional managers are listed at their website.  

Answers to cost-share questions typically can be found by using the TRICARE Compare Cost Tool. To resolve billing questions, your first step should be to
access your TRICARE Explanation of Benefits (EOB) to know specifically what medical service that co-pay represents. EOBs can be downloaded from your regional manager’s website or by calling the regional manager.

[FROM TRICARE.MIL: How to File a Grievance]

Each TRICARE contracting agent, including Express Scripts for pharmacy issues, usually can handle grievances or appeals through their websites or by calling customer service numbers.

Medicare and TFL

Medicare beneficiaries may consult their provider’s patient advocates or Medicare for billing or claims dispute. TFL billing/payment hiccups, or in the rare event that TRICARE covers a medical service that Medicare does not, should be referred to the TFL administrator Wisconsin Physicians Service at 866-773-0404 or www.tricare4u.com.

Appeals

When denied a medical benefit, you can appeal for reasons including:

• TRICARE stopped payment for services previously authorized.
• TRICARE deemed services not medically necessary.
• A pharmacy benefit was denied.
• Medicare denied service or supplies (if you are eligible for both TRICARE and Medicare).

If your care is denied, you will receive a letter with details about how to file your appeal.