Tricare Help -- Initial Tricare for Life claim can be tricky

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Subject: Tricare Help -- Initial Tricare for Life claim can be tricky

 
http://tricare.osd.mil/eenews/downloads/030706 TRICARE Help.doc

March 13, 2006
Army Times

Tricare Help
Initial Tricare for Life claim can be tricky

By James E. Hamby Jr.
Special to the Times

Q. I turned 65 on Dec. 16. Everything went just like you say it should: I got my Medicare ID card showing I was enrolled in parts A and B, effective Dec. 1. And as I did not cancel my Part B enrollment, I knew I had Tricare for Life as of that date.

When I went to my doctor Dec. 2, I showed my Medicare card and my military ID card and told them I was on Tricare for Life. Everything went just fine — until I got a bill from the doctor for $168.

Tricare did not pay the balance on my Medicare claim. When I called to ask why, they said they didn’t get a claim from Medicare. They told me I wasn’t even in their computer. I’ve been filing Tricare claims for years. How can I not be in their computer?

The claim bounced around for a month before it was finally paid. Now I’m concerned about the mix-up. Claims since then have been paid, but I’m always afraid I’ll get a big bill and Tricare for Life won’t pay.


A. I believe two things contributed to your problem. First is the law that created CHAMPUS (now Tricare) in 1966, as modified in 1991. It says that if anybody except an active-duty family member gets Medicare Part A, he automatically loses Tricare eligibility unless enrolled in Medicare Part B.

Second is the requirement for the beneficiary’s Defense Enrollment Eligibility Reporting System record to be updated to show he is enrolled in Part B.
Tricare uses DEERS on every claim to verify that patients were eligible for Tricare on the date their medical care was received.

Almost all Americans become eligible for full Social Security benefits, including Medicare, when they turn 65. Unless DEERS records are updated to show Part B enrollment, DEERS will report them as ineligible for Tricare on the first day of the month they turn 65.
The few people ineligible for Social Security and Medicare at that age must apply to Social Security for a Notice of Disallowance, which they must send to DEERS.

DEERS will report them to be ineligible for Medicare and having continuing Tricare eligibility beyond age 65. Note that they do not get Tricare for Life, as do Medicare-eligible people; they continue to be covered by “ordinary” Tricare.

Medicare notifies DEERS when a Tricare beneficiary gets Medicare and is enrolled in Part B. When the information is sent by Medicare — and updated by DEERS — in a timely manner, the beneficiary is reported to be eligible for Tricare for Life. The system, unfortunately, isn’t set up to automatically transmit that information electronically. Sometimes notification, or posting to the DEERS database, is delayed. Then claims such as yours will be denied.

The Medicare portion of the claim can be processed because Medicare has its own eligibility reporting system. When your doctor filed a Medicare claim, Medicare paid its share to the doctor. Then Medicare forwarded your claim to Tricare as usual. Obviously, Tricare processed the claim before your DEERS record was updated. When the DEERS computer was queried, it reported you ineligible for Tricare.

A special contractor processes the Tricare portion of Tricare for Life claims.
When your claim was processed and denied, it should have left a record in the computer. As this was your first Tricare for Life claim, however, you had no past record.
You’re not the only Tricare for Life beneficiary this has happened to. I asked the DEERS Support Office how to avoid your problems, and here’s what they told me:

• Two or three weeks before the first day of the month when beneficiaries turn 65, they will get a letter from Medicare showing they have been awarded Part A and Part B of Medicare, with coverage effective on the first day of the coming month. The letter will include the beneficiary’s Medicare ID card showing the same information.

• The beneficiary should immediately send a copy of the letter, or of the Medicare ID card, to the nearest uniformed service facility that has authority to issue military ID cards.
• If proof is to be mailed, the DEERS Support Office said to advise beneficiaries to call there first at (800) 538-9552.The office will provide a phone number for the proper uniformed service office, which you should call for instructions about mailing a copy of the Medicare award letter to prove Part B enrollment.

• The receiving office will have computer access to DEERS and can update beneficiary records immediately to show Part B enrollment and Tricare for Life eligibility.



James E. Hamby Jr. may be reached by writing to Tricare Help,

Times News Service,
6883 Commercial Drive,
Springfield, VA 22159;
or by e-mailing tricarehelp@atpco.com.

In e-mail, please include the word Tricare in the subject line and do not attach files. If using regular mail, please include an e-mail address for a faster response.
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Contributed,
YNCS Don Harribine, USN(ret)