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How does TRICARE pay when I have Other Health Insurance?


When you have Other Health Insurance (OHI), TRICARE is secondary. Before TRICARE considers the claim, your OHI must pay first. The exceptions are Medicaid and TRICARE supplemental plans.

After your OHI has paid, you may submit your claim to TRICARE, along with a copy of the Explanation of Benefits (EOB) from your other insurance. TRICARE's payment varies depending on several factors, such as whether your doctor is contracted to TRICARE or to your other insurance carrier.

To understand how TRICARE pays when you have other insurance, keep in mind the TRICARE maximum allowable charge. This is the maximum amount TRICARE will reimburse a doctor for each procedure. Another thing to keep in mind is whether or not your doctor "accepts assignment," also known as a Participating Provider.

Doctors who "accept assignment" agree to accept the TRICARE reimbursement as full payment.

 

Participating Providers

In double coverage situations, TRICARE will pay the lower of:

  • The amount TRICARE would have paid as primary payor; or
  • The lesser of:

                                1.  Up to the billed amount; or

                                2.  The Other Health Insurance allowed amount after the primary insurance plan has paid its

                                     benefits.

 

The provider cannot bill the beneficiary for anything above the TRICARE Allowed Amount.

 

Non-Participating Providers
Federal law limits the amount you can be billed if your doctor does not accept assignment on the claim. When a provider does not accept assignment, the provider can be paid no more than 115% of the TRICARE allowable charge by law. 

In double coverage situations, TRICARE will pay the lower of:

  • The billed charges; or
  • 115% of the TRICARE maximum allowable charge

 

 


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