TRICARE

Reserve Select Handbook

Important Information
TRICARE Reserve Select Web Site: www.tricare.mil/reserve/reserveselect
Reserve Affairs Web Site: www.defenselink.mil/ra
Guard/Reserve Portal Address: https://www.dmdc.osd.mil/appj/trs/index.jsp
TRICARE National Web Site: www.tricare.mil
TRICARE Mail Order Pharmacy: 1-866-DoD-TMOP (1-866-363-8667)
TRICARE Retail Network Pharmacy: 1-866-DoD-TRRX (1-866-363-8779)

TRICARE North Region Contractor

Health Net Federal Services, LLC (Health Net): 1-800-555-2605
Health Net Web Site: www.healthnetfederalservices.com

TRICARE South Region Contractor

Humana Military Healthcare Services, Inc. (Humana Military): 1-800-444-5445
Humana Military Web Site: www.humana-military.com

TRICARE West Region Contractor

TriWest Healthcare Alliance, Corp.(TriWest): 1-888-TRIWEST (1-888-874-9378)
TriWest Web Site: www.triwest.com

TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific)
Overseas Toll-Free Number: 1-888-777-8343
Overseas Web Site: www.tricare.mil/overseas

An Important Note About TRICARE Program Changes

At the time of printing, the information in this handbook is current. It is important to remember that TRICARE
policies and benefits are governed by public law. Changes to TRICARE programs are continually made as public law
is amended. For the most recent information, contact your regional contractor or local TRICARE Service Center.
More information regarding TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA)
Notice of Privacy Practices, can be found online at www.tricare.mil.
TRICARE Reserve Select
TRICARE Reserve Select (TRS) is a premium-
based health plan that qualified National Guard
and Reserve members may purchase unless
eligible for coverage under the Federal Employees
Health Benefits program (FEHB). If either the
member or spouse is eligible to purchase the
FEHB then the member and family are not
eligible to purchase TRS.
We use the terms National Guard and Reserve
throughout this handbook to include:
• Army National Guard
• Army Reserve
• Navy Reserve
• Marine Corps Reserve
• Air National Guard
• Air Force Reserve
• U.S. Coast Guard Reserve
TRS offers coverage similar to TRICARE
Standard and TRICARE Extra, and a monthly
premium will be charged. You will receive
comprehensive coverage with access to
TRICARE-authorized providers. Annual
deductibles, cost-shares, and a catastrophic cap
apply. You may access care from a military
treatment facility (MTF) on a space-available
basis only. You may fill prescriptions through the
MTF, the TRICARE mail-order pharmacy, and
TRICARE retail network and non-network
1
pharmacies. Costs for prescription medications
vary depending upon the pharmacy option you
choose and the medication’s availability on the
uniform formulary.
For more information about TRS coverage, visit
www.tricare.mil/reserve/reserveselect. For more
information about the National Guard and Reserve
and the Selected Reserve, visit the Reserve Affairs
Web site at www.defenselink.mil/ra.
Programs Not Available with
TRICARE Reserve Select
If you are enrolled in TRS, you may not
participate in the following programs:
• Special Supplemental Food Program
• TRICARE Extended Care Health Option
(ECHO)
• TRICARE Global Remote Overseas (TGRO)
• TRICARE Prime
• TRICARE Prime Remote (TPR)
• TRICARE Prime Remote for Active Duty
Family Members (TPRADFM)
• TRICARE Prime Overseas
• TRICARE Puerto Rico Prime
• TRICARE Reserve Family Demonstration
Project
• US Family Health Plan (USFHP)
Your TRICARE Regional Contractor

We often refer to your regional contractor throughout this handbook and describe differences in each
region. In cases where there are regional differences, refer to the information specific to your region.
Besides offering toll-free customer service telephone lines and Web sites, each regional contractor
operates TRICARE Service Centers throughout the region, typically at or near military installations,
which offer customer service support. The following descriptions of each TRICARE region include
contact information for each regional contractor.

WEST
NORTH

SOUTH

TRICARE North Region TRICARE West Region

The TRICARE North Region includes
Connecticut, Delaware, the District of Columbia,
Illinois, Indiana, Kentucky, Maine, Maryland,
Massachusetts, Michigan, New Hampshire,
New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Rhode Island, Vermont, Virginia,
West Virginia, Wisconsin, and portions of Iowa
(Rock Island Arsenal area), Missouri (St. Louis
area), and Tennessee (Ft. Campbell area).
Regional Health Net Federal Services, LLC
contractor (Health Net)
Phone 1-800-555-2605
Web site www.healthnetfederalservices.com
The TRICARE West Region includes Alaska,
Arizona, California, Colorado, Hawaii, Idaho,
Iowa (excluding Rock Island Arsenal area),
Kansas, Minnesota, Missouri (excluding the St.
Louis area), Montana, Nebraska, Nevada, New
Mexico, North Dakota, Oregon, South Dakota,
Texas (the southwestern corner, including
El Paso), Utah, Washington, and Wyoming.
Regional TriWest Healthcare Alliance Corp.
contractor (TriWest)
Phone 1-888-TRIWEST (1-888-874-9378)
Web site www.triwest.com

TRICARE South Region
The TRICARE South Region includes Alabama,
Arkansas, Florida, Georgia, Louisiana,
Mississippi, Oklahoma, South Carolina,
Tennessee (excluding the Ft. Campbell area),
and Texas (excluding the El Paso area).
TRICARE Overseas
TRS is available overseas. The TRICARE overseas
areas include TRICARE Europe, TRICARE Latin
America and Canada (TLAC), and TRICARE
Pacific. The TRICARE South Region contractor,
Humana Military, handles enrollment, billing, and
customer support services for these overseas areas.

Regional Humana Military Healthcare Regional Humana Military Healthcare

contractor Services, Inc. (Humana Military) contractor Services, Inc. (Humana Military)

Phone 1-877-298-3408 Phone 1-877-298-3408

Web site www.humana-military.com Web site www.humana-military.com

2
TRICARE Europe includes Africa, Europe, and
the Middle East. TLAC includes Canada, the
Caribbean Basin, Central and South America,
Puerto Rico, and the Virgin Islands. TRICARE
Pacific includes Asia, Australia, Guam, India,
Japan, Korea, New Zealand, and remote Western
Pacific countries.
The U.S. Department of State provides several
useful resources, including a Web site listing
U.S. Embassies and Consulates. A TRICARE
point of contact is located at each U.S. Embassy
and Consulate. Locate a U.S. Embassy or
Consulate at www.usembassy.gov.

TRICARE Service Centers (TSCs) can provide

information about locating a provider or
accessing health care in overseas locations.
Contact the TRICARE Area Office in your
overseas area to locate a TSC near you.

TRICARE Area Office Contact Information

TRICARE Europe TLAC TRICARE Pacific

Phone Toll-free: 1-888-777-8343, Toll-free: 1-888-777-8343, Toll-free: 1-888-777-8343,
Option 1 Option 3 Option 4
Comm.: 011-49-6302-67-7432 Comm.: 1-706-787-2424 Comm.: 011-81-6117-43-2036
DSN: 496-7432 DSN: 773-2424 DSN: 643-2036
Remote Sites: 011-65-6-338-9277
Fax Comm.: 011-49-6302-67-6374 1-706-787-3024 Comm.: 011-81-6117-43-2037
DSN: 496-6374 DSN: 643-2037
E-mail teurope@europe.tricare.mil tricare15@se.amedd.army.mil TPAO.CSC@oki10.med.navy.mil

Online www.tricare.mil/europe www.tricare.mil/tlac www.tricare.mil/pacific

3
Table of Contents
1. Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Finding a Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
TRICARE Reserve Select Wallet Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Care at a Military Treatment Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Prior Authorization for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Getting Care While Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Getting Care Overseas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

2. Covered Services, Limitations, and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

3. Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Overseas Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Coordinating Benefits with Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Third-Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

4. Changes to Your TRICARE Reserve Select Coverage . . . . . . . . . . . . . . . . . . . . . . 26

Changes to Your Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Coverage for Newborns or Adopted Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
When TRICARE Reserve Select Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
TRICARE Reserve Select Survivor Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5. Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Qualifying for TRICARE Reserve Select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Updating DEERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

4
6. Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

7. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Sample Explanation of Benefits Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

9. List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

10. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

For information about your patient rights and responsibilities, see the inside back cover of this
handbook.

5
Getting Care
Finding a Provider
With TRICARE Reserve Select (TRS) you may
receive care from any TRICARE-authorized
provider without a referral. Some services will
require prior authorization (discussed later in
this section). Figure 1.1 describes the different
types of providers.
You may use either a TRICARE network provider
or a non-network, TRICARE-authorized provider
at any time. For example, if an orthopedic surgeon
and a physical therapist are treating you, one could
be a TRICARE network provider and the other
could be a non-network, TRICARE-authorized
provider. Ask if your health care provider(s) is a
TRICARE network provider. Visits to a TRICARE
network provider will cost you less out of pocket,
and the provider will file claims on your behalf.
With a non-network, TRICARE-authorized
provider, you’ll pay more out of pocket and may
have to file your own claims.
To find a TRICARE network provider or a
non-network, TRICARE-authorized provider,
visit the provider locator at
www.tricare.mil/ProviderDirectory. The
regional contractors also have TRICARE
network provider directories on their Web sites,
which you may use to locate providers in each
region. If you do not have Internet access, call
your regional contractor for assistance locating
a provider.
Note: For information about finding a provider
overseas, see “Getting Care Overseas” later in
this section.

TRICARE Provider Types Figure 1.1

TRICARE-Authorized Providers

• TRICARE-authorized providers are those who meet TRICARE’s licensing and certification requirements and
have been certified by TRICARE to provide care to TRICARE beneficiaries. These include doctors, hospitals,
ancillary providers (such as laboratories and radiology centers), and pharmacies. If you see a provider who is
not TRICARE-authorized, you are responsible for the full cost of care.
• There are two types of TRICARE-authorized providers: Network and Non-network.

Network Providers Non-Network Providers

• Have a signed agreement with your • Do not have a signed agreement with your regional contractor.
regional contractor to provide care.
• There are two types of non-network providers: Participating and
• Agree to handle claims for you. Nonparticipating.
• Using a network provider is your Participating Nonparticipating
best option.
• May choose to participate on a • Have not agreed to accept the
claim-by-claim basis TRICARE-allowable charge or file
your claims.
• Have agreed (when participating)
to file claims for you, to accept • Have the legal right to charge you
payment directly from TRICARE, up to 15% above the TRICARE-
and to accept the TRICARE- allowable charge for services. You
allowable charge, (less any are responsible for paying this
applicable patient cost-shares paid amount in addition to any
by you) as payment in full for their applicable patient cost-share.
services.
• If you visit a nonparticipating
• Using a participating provider is provider, you may have to pay the
your best option if seeing a non- provider first and file a claim with
network provider. TRICARE for reimbursement.

6
 GETTING CARE
SECTION 1
TRICARE Reserve Select Emergency Care
Wallet Card
TRICARE defines an emergency as a medical,
You and each covered family member should maternity, or psychiatric condition that would lead
receive (or may already have received) a TRS a “prudent layperson” (someone with average
wallet card when your TRS enrollment is knowledge of health and medicine) to believe that
processed through the Defense Enrollment a serious medical condition exists; that the absence
Eligibility Reporting System (DEERS). TRS of medical attention would result in a threat to
wallet cards contain key phone numbers and the patient’s life, limb, or sight; that the patient
other information to assist you with your health requires immediate medical treatment; or that the
care coverage. If your doctor, hospital, pharmacist, patient has painful symptoms requiring immediate
durable medical equipment supplier, or other attention to relieve suffering.
provider asks to see your insurance card, you
may present this card. If you require emergency care, call 911 or go to
the nearest emergency room. If you are admitted,
If you do not receive your TRS wallet card you may need to obtain authorization (depending
within four to six weeks of submitting your TRS on the type of care) by contacting your regional
Request form, contact your regional contractor contractor.
for assistance.

Care at a Military Treatment

TRS Wallet Card (front)
TRICARE: The World’s Best Health Care
for the World’s Best Military
Facility
Figure 1.2
A military treatment facility (MTF) is a military
hospital or clinic, usually located on or near a
military installation. You may receive care at

E
TRICARE Reserve Select
an MTF on a space-available basis only. MTF
TRS Member: John Q. Sample

P L appointments are limited, and you will be

M
Effective Date: 01 Jan 2000 assigned the lowest priority for receiving MTF

S A
Covered Person: Susie Q. Sample

The TRS identification number is the TRS

member’s Social Security Number.
ww w.tricare.mil
care. To locate an MTF, access the MTF Locator
at www.tricare.mil/mtf.

Prior Authorization for Care

TRS Wallet Card (back) Figure 1.3
You may access care from any TRICARE-
authorized provider you choose whenever you
This card is not a guarantee of coverage. Coverage under TRS is separate from
any medical coverage indicated on the military identification card. TRS benefits need it. Referrals are not required, but some
are available from TRICARE-authorized providers and TRICARE Network
providers. Pre-certification is required for inpatient mental health and selected services will require prior authorization.
regionally-determined procedures.

TRICARE Regional Contractor

P L E xxx-xxx-xxxx
xxx.xxxx.xxx A prior authorization is a review of the requested

A M
TRICARE Retail Pharmacy xxx-xxx-xxxx
health care service to determine if it is medically

S
TRICARE Mail Order Pharmacy xxx-xxx-xxxx
http://xxxxx/xxxxx/xxxxx/xxxxx.xxx necessary at the requested level of care. Prior
authorizations must be obtained prior to services
In EMERGENCY—dial 911 or go to the nearest
emergency medical facility. being rendered or within 24 hours of an admission.
Some providers may call the regional contractor to
obtain prior authorization for you. If you have
questions about your authorization requirements,
call your regional contractor or visit their Web site
for assistance before seeking care.

7
The following services* require prior
authorization in all three TRICARE regions:
• Adjunctive dental services
• Extended Care Health Option (ECHO) services
• Home health services
• Hospice care
• Nonemergency inpatient admissions for
substance use disorders and behavioral health
• Outpatient behavioral health care beyond
the eighth visit each fiscal year (October 1–
September 30)
• Transplants—all solid organ and stem cell
* This list is not intended to be all-inclusive.
Each regional contractor has additional prior
authorization requirements. Visit your regional
contractor’s Web site or call their toll-free
number to learn about your region’s
requirements, as they may change periodically.
Getting Care Overseas
You may receive care from any qualified
host-nation provider without a referral. We
recommend that you contact your TRICARE
Service Center (TSC), TRICARE Area Office
(TAO), or the nearest U.S. Embassy Health Unit
for assistance in locating a provider. Locate a
U.S. Embassy or Consulate by visiting
www.usembassy.gov.
Prior Authorization Requirements
Overseas
Since authorization requirements may vary by
overseas area, contact the nearest overseas TAO
for assistance before seeking care. See Figure
3.2, “Overseas Claims Addresses,” in the Claims
section of this handbook for TAO contact
information.

Note: For overseas prior authorization

information, see “Getting Care Overseas” later
in this section.

Getting Care While Traveling

While you are traveling, you may visit any

TRICARE network provider or any non-network,
TRICARE-authorized provider. You may be
required to pay non-network providers directly
and file your claim with your regional contractor
for reimbursement (See the Claims section of this
handbook.). You should file the claim with the
contractor in your home region, not in the region
in which you received the care. You will find
claim forms at www.tricare.mil/claims. In
the right-hand navigation column, look for
“Downloads.” Then click on “TRICARE Claim
Form (DD Form 2642).”

8
 GETTING CARE
SECTION 1
Covered Services, Limitations, and Exclusions
TRICARE Reserve Select (TRS) covers most care that is medically necessary and considered proven.
However, there are special rules or limits on certain types of care, while other types of care are not
covered at all. This section is not intended to be all-inclusive. Check with your regional contractor
for additional information.

Outpatient Services

Figure 2.1 provides coverage details for covered outpatient services. This chart is not intended to be
all-inclusive.

COVERED SERVICES, LIMITATIONS & EXCLUSIONS

SECTION 2
Outpatient Services: Coverage Details Figure 2.1

Service Description
Ambulance Services Covers emergency transfers to or from a beneficiary’s home, accident scene, or other
location to a hospital; transfers between hospitals; ambulance transfers from a
hospital-based emergency room to a hospital more capable of providing the required
care; and transfers between a hospital or skilled nursing facility and another hospital-
based or freestanding outpatient therapeutic or diagnostic department/facility.
Excludes ambulance service used instead of taxi service when the patient’s condition
would have permitted use of regular private transportation; transport or transfer of a
patient primarily for the purpose of having the patient nearer to home, family, friends,
or personal physician; and medicabs or ambicabs that function primarily as public
passenger conveyances transporting patients to and from their medical appointments.
Ancillary Services Covers certain diagnostic radiology and ultrasound; diagnostic nuclear medicine;
pathology and laboratory services; and cardiovascular studies.

Durable Medical Generally covered if medically necessary and appropriate, and if prescribed by a
Equipment (DME) physician for the specific use of the beneficiary. Duplicate items of DME that are
essential to provide a fail-safe, in-home, life-support system are covered. In this case,
“duplicate” means an item that meets the definition of DME and serves the same
purpose but may not be an exact duplicate of the original DME item. For example, a
portable oxygen concentrator may be covered as a backup for a stationary oxygen
generator.
Emergency Services Emergency services are covered for medical, maternity, or psychiatric conditions that
would lead a “prudent layperson” (someone with average knowledge of health and
medicine) to believe that a serious medical condition exists; that the absence of
medical attention would result in a threat to the patient’s life, limb, or sight; that the
patient may be a danger to self or others and requires immediate medical treatment;
or that the patient has painful symptoms requiring immediate attention to relieve
suffering.
Home Health Care Covers part-time or intermittent skilled nursing services and home health services;
physical, speech, and occupational therapy; medical social services; and routine and
non-routine medical services. All care must be provided by a participating home
health care agency and be authorized in advance by the regional contractor.
Individual Provider Covers office visits; outpatient office-based medical and surgical care; consultation,
Services diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic
manipulation; rehabilitation services (e.g., physical therapy, speech pathology
services, and occupational therapy); and medical supplies used within the office.
Laboratory and Generally covered if prescribed by a physician. (Some exceptions apply, e.g., chemo-
X-Ray Services sensitivity assays and bone density X-ray studies for routine osteoporosis screening
are not covered.)
Prosthetic Devices and Generally covered if prescribed by a physician and if directly related to a medical
Medical Supplies condition. Prosthetic devices must be FDA approved.

9
Inpatient Services

Figure 2.2 provides coverage details for covered inpatient services. This chart is not intended to be
all-inclusive.

Inpatient Services: Coverage Details Figure 2.2

Service Description
Hospitalization Covers semiprivate room (and when medically necessary, special care units), general
nursing, and hospital service. Includes inpatient physical and surgical services; meals
(including special diets); drugs and medications while an inpatient; operating and
recovery room; anesthesia; laboratory tests; X-rays and other radiology services;
necessary medical supplies and appliances; and blood and blood products.
Skilled Nursing Covers semiprivate room; regular nursing services; meals, including special diets;
Facility (SNF) Care physical, occupational, and speech therapy; drugs furnished by the facility; and necessary
medical supplies and appliances. Unlike Medicare, TRICARE covers an unlimited
number of days as medically necessary.

Clinical Preventive Services

Figure 2.3 provides coverage details for covered clinical preventive services. This chart is not intended
to be all-inclusive.

Clinical Preventive Services: Coverage Details Figure 2.3

Service Description
Health Promotion Office visits may be covered for the following services (subject to age and other criteria):
and Disease • Cancer screening examinations and services (breast cancer, cancer of female
Prevention reproductive organs, colorectal cancer, and prostate cancer)
Examinations
• Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV]
testing) and preventive therapy when at-risk (tetanus, animal bite, Rh immune globulin,
and exposure to certain infectious diseases, including tuberculosis)
• Genetic testing and counseling for certain clinical indications during pregnancy
• Other: routine chest X-rays and electrocardiograms required for admission when a
patient is scheduled to receive general anesthesia on an inpatient or outpatient basis
Immunizations Covered for age-appropriate dose of vaccines, including influenza, as recommended by the
Centers for Disease Control and Prevention (CDC). Coverage for human papillomavirus
(HPV) vaccine provided for initial administration for girls age 11-12, or if not previously
administered, for girls age 13-26.
Other Health The following services may be covered if provided in connection with a visit for
Promotion and immunizations, Pap smears, mammograms, or examinations for colon and prostate cancer:
Disease Prevention • Cancer screening (testicular, skin, oral cavity and pharyngeal, and thyroid)
Services
• Infectious disease (tuberculosis screening, Rubella antibodies)
• Cardiovascular disease (cholesterol screening, blood pressure screening)
• Body measurements (height and weight)
• Vision screening
• Audiology screening (only allowed under well-child services)
• Counseling services expected of good clinical practice that are included with the
appropriate office visit at no additional charge (dietary assessment and nutrition;
physical activity and exercise; cancer surveillance; safe sexual practices; tobacco,
alcohol, and substance abuse; promoting dental health; accident and injury prevention;
and stress, bereavement, and suicide risk assessment)

10
Clinical Preventive Services: Coverage Details (continued)
Service Description
Pap Smear Covered as either a diagnostic or routine preventive procedure. The human
papillomavirus (HPV) Pap test is not covered as a routine screening Pap smear.
School Physicals Covered for children ages 5–11 if required in connection with school enrollment.
Note: Annual school sports physicals are not covered.

Well-Child Care Covered from birth to age 6; includes office visits, immunizations, and vision screening.

Behavioral Health Care Services If you are unsure which type of provider would

COVERED SERVICES, LIMITATIONS & EXCLUSIONS

SECTION 2
best meet your needs, contact your regional
You may receive your first eight behavioral contractor for assistance.
health outpatient visits per fiscal year
(October 1–September 30) without prior Figure 2.4 on the following page provides
authorization from your regional contractor. coverage details for covered behavioral health
After the first eight visits, prior authorization is care services. This chart is not intended to be
required. Remember to obtain care only from all-inclusive. For additional information about
TRICARE network providers or non-network, covered and non-covered behavioral health care
TRICARE-authorized providers. The following services and how to access care, contact your
types of behavioral health providers may be regional contractor.
authorized providers under TRICARE:
• Psychiatrists
• Clinical psychologists
• Clinical psychiatric nurse specialists
• Clinical social workers
• Certified marriage and family therapists with a
TRICARE participation agreement
• Pastoral counselors—with physician referral
and supervision
• Mental health counselors—with physician
referral and supervision

11
Behavioral Health Care Services: Coverage Details Figure 2.4

Service Description
Acute Inpatient Acute inpatient psychiatric care may be covered on an emergency or nonemergency
Psychiatric Care basis. Prior authorization from your regional contractor is required for all
nonemergency inpatient admissions. In emergency situations, authorization is
required for continued stay.
Limitations
• Patients age 19 and older are limited to 30 days per fiscal year.*
• Patients age 18 and younger are limited to 45 days per fiscal year.*
• Inpatient admissions for substance use disorder detoxification and rehabilitation
count toward the 30- or 45-day limit.
Medication If you are taking prescription medications for a behavioral health condition, you must
Management be under the care of a provider who is authorized to prescribe those medications. Your
provider will manage the dosage and duration of your prescription to ensure you are
receiving the best care possible.
Psychiatric Psychiatric partial hospitalization provides interdisciplinary therapeutic services at
Partial Hospitalization least three hours per day, five days a week, in any combination of day, evening, night,
and weekend treatment programs.
• Prior authorization from your regional contractor is required.
• Facility must be TRICARE-authorized.
• Psychiatric partial hospitalization programs must agree to participate in TRICARE.
Limitations
• Limited to 60 treatment days (whether a full- or partial-day treatment) in a fiscal
year.* These 60 days are not offset by or counted toward the 30- or 45-day inpatient
limit.
Psychological Testing Covered when medically or psychologically necessary and provided in conjunction
and Assessment with otherwise-covered psychotherapy. Psychological tests are considered to be
diagnostic services and are not counted against the limit of two psychotherapy visits
per week.
Limitations
Testing and assessment is generally limited to six hours in a fiscal year.
Exclusions
Psychological testing is not covered for the following circumstances:
• Academic placement
• Job placement
• Child custody disputes
• General screening in the absence of specific symptoms
• Teacher or parental referrals
• Diagnosing specific learning disorders or learning disabilities

* The fiscal year is October 1–September 30.

12
Behavioral Health Care Services: Coverage Details (continued)
Service Description
Psychotherapy Prior authorization is required after the first eight behavioral health outpatient visits per
beneficiary, per fiscal year.* Covered psychotherapy includes:
• Individual, conjoint, family, or group sessions
• Collateral visits
• Play therapy (a form of individual therapy used with children)
• Psychoanalysis (prior authorization from your regional contractor required)
Limitations
• Outpatient psychotherapy is limited to a maximum of two sessions per week in any
combination of individual, family, collateral, or group sessions, and is not covered when
the patient is an inpatient in an institution.

COVERED SERVICES, LIMITATIONS & EXCLUSIONS

SECTION 2
• Inpatient psychotherapy is limited to five sessions per week in any combination of
individual, family, collateral, or group sessions. The duration and frequency of care is
dependent upon medical necessity.
Residential RTC care provides extended care for children and adolescents with psychological disorders
Treatment Center that require continued treatment in a therapeutic environment.
(RTC) Care • Unless therapeutically contraindicated, the family and/or guardian must actively
participate in the continuing care of the patient either through direct involvement at the
facility or geographically distant family therapy.
• Facility must be TRICARE-authorized.
• Prior authorization from your regional contractor is required.
• RTC care is considered elective and will not be covered for emergencies.
• Admission primarily for substance use rehabilitation is not authorized.
• Care must be recommended and directed by a psychiatrist or clinical psychologist.
Limitations
• Limited to 150 days per fiscal year* (may be waived if determined to be medically or
psychologically necessary)
Note: No qualified RTCs were available in overseas locations at time of printing.

* The fiscal year is October 1–September 30.

13
Behavioral Health Care Services: Coverage Details (continued)
Service Description
Treatment for A substance use disorder includes alcohol or drug abuse or dependence. TRICARE may
Substance Use cover services for the treatment of substance use disorders, including detoxification,
Disorders rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospital
services are considered medically necessary only when the patient’s condition is such that
the personnel and facilities of a hospital are required.
Note: All treatment for substance use disorders requires prior authorization from your
regional contractor.
Coverage and Limitations
• Benefit period—Only three substance use disorder treatment benefit periods in a lifetime
are covered (waiver possible in accordance with policy criteria). A benefit period begins
with the first date of covered treatment and ends 365 days later, regardless of the total
services actually used within the benefit period. Emergency and inpatient hospital services
for detoxification, stabilization, and treatment of medical complications of substance use
disorders do not count for purposes of establishing the beginning of a benefit period.
• Detoxification—If chemical detoxification is needed but does not require the personnel
or facilities of a general hospital setting, detoxification services are covered in addition to
rehabilitative care. In a diagnosis-related group (DRG)-exempt facility, detoxification
services are limited to seven days per year, unless the limit is waived.
• Rehabilitation—Rehabilitation (residential or partial) is limited to 21 days per year or
one inpatient stay in a facility subject to the DRG-based reimbursement system, per
benefit period; you are limited to three benefit periods in your lifetime. All inpatient stays
count toward the 30- or 45-day inpatient limit.
• Outpatient Care—Must be provided by an approved substance use disorder facility in a
group setting. Coverage is limited to 60 visits per fiscal year.* Individual outpatient care
for substance use disorder is not covered.
• Family Therapy—Outpatient family therapy is covered beginning with the completion of
rehabilitative care. You are covered for up to 15 visits in a benefit period.

* The fiscal year is October 1–September 30.

Pharmacy Services TRICARE Mail Order Pharmacy

TRICARE offers comprehensive prescription drug
coverage and several options for filling your
prescriptions. To have a prescription filled, you’ll
need a written prescription. If your pharmacist asks
for your insurance card, you should provide your
TRS wallet card. Visit www.tricare.mil/pharmacy
for pharmacy cost information.
Military Treatment Facility Pharmacy
Prescriptions may be filled (up to a 90-day
supply for most medications) at an MTF
pharmacy at no cost as long as the medication
is on the MTF formulary. You should contact
the MTF pharmacy to find out what is on the
formulary and for specific details about filling
prescriptions there.
The mail-order pharmacy is your least expensive
option when not using the MTF. You may receive
up to a 90-day supply for most medications
delivered to your home for a small copayment.
Refills may be requested by mail, phone, or
online. Registering for the mail-order pharmacy
is easy:
1. Register online. Go to
www.tricare.mil/pharmacy and click on
“Filling Prescriptions.” Then select “How to
Register” in the left-hand navigation column.
Complete the online registration form and
follow the instructions for submission.
2. Register by phone. Call 1-866-363-8667 (in
the United States). If overseas, call
1-866-ASK-4PEC (1-866-275-4732).

14
3. Register by mail. Download the registration
form at www.tricare.mil/pharmacy and mail
it to:
TRICARE Mail Order Pharmacy
P.O. Box 52150
Phoenix, AZ 85072-9954
Include the written prescription and the appropriate
copayment when you mail your registration.
For faster processing of your mail-order
prescription, you may register before placing
your first order. Once you are registered, your
Non-Network Pharmacy
Filling prescriptions at a non-network pharmacy is
the most expensive option. You may have to pay
for the total amount first and then file a claim to
receive a partial reimbursement from TRICARE
after your deductible is met. (For more information
about pharmacy claims, see the Claims section of
this handbook.)
Quantity Limits and Prior
Authorization
TRICARE has established quantity limits on

COVERED SERVICES, LIMITATIONS & EXCLUSIONS

SECTION 2
certain medications, which means that the
provider can fax or call in your prescriptions.
Department of Defense (DoD) will only pay for
a specified amount (a 30-, 60-, or 90-day supply)
You can convert maintenance prescriptions
of medication. Quantity limits are applied to
(prescriptions you take on a regular basis)
ensure the medications are safely and
that you have filled at a TRICARE Retail Network
appropriately used. Exceptions to established
Pharmacy to the TRICARE Mail Order Pharmacy
quantity limits may be made if the prescribing
via the Member Choice Center (MCC). To convert
provider is able to justify medical necessity.
online, go to www.tricare.mil/pharmacy and
click on "Filling Prescriptions." Then select
Some drugs require prior authorization. For a
"Convert Retail Prescriptions" in the left-hand
general list of prescription drugs that are covered
navigation column and follow the instructions
under TRICARE, and for drugs that require prior
to convert online. To convert by phone, call
authorization or have quantity limits, visit
1-877-363-1433. A trained MCC Patient Care
www.tricare.mil/pharmacy and click on
Advocate will walk you through the process and
“Medications.” Then, from the left-hand
convert your medication(s) to home delivery.
navigation bar, select “Prior Authorization.” If
you don’t have Internet access, you can call
Your medications will be sent directly to your
toll-free 1-866-DoD-TRRX (1-866-363-8779)
home within approximately 14 days after your
or 1-866-DoD-TMOP (1-866-363-8667).
prescription is received. If you have prescription
drug coverage from another health insurance
Generic Drug Use Policy
plan, you can use the mail-order pharmacy if the
medication is not covered under the other plan or It is DoD policy to use generic medications, instead
if you exceed the dollar limit of coverage under of brand-name medications, whenever possible.
the other plan. Brand-name drugs that have a generic equivalent
may be dispensed only if the prescribing physician
TRICARE Retail Network Pharmacy is able to justify medical necessity for use of the
brand-name drug in place of the generic equivalent.
You may have prescriptions filled (up to a 30-
If a generic equivalent does not exist, the brand-
day supply) at any pharmacy in the TRICARE
name drug will be dispensed at the brand-name
retail network for a small copayment. For more
copayment. If you insist on having a prescription
information or to locate a TRICARE retail
filled with a brand-name drug that is not considered
network pharmacy, call 1-866-DoD-TRRX
medically necessary, and when a generic equivalent
(1-866-363-8779) or visit
is available, you will be responsible for paying the
www.tricare.mil/pharmacy.
entire cost of the prescription out of pocket.
Note: Retail network pharmacies are available in
the United States, American Samoa, Guam, the
Northern Mariana Islands, Puerto Rico, and the
U.S. Virgin Islands.
15
Non-Formulary Drugs
Any drug determined to be not as clinically
effective or not as cost-effective as other drugs in
its therapeutic class may be recommended for
placement in the “non-formulary” classification.
Non-formulary drugs are available to beneficiaries
from the mail-order or retail pharmacies at a
higher cost. You may be able to have non-
formulary prescriptions filled at the formulary
costs if your provider can establish medical
necessity. Note: Non-formulary drugs are
generally not available at MTFs.
To learn more about medications and common
drug interactions, to check for generic equivalents,
or to determine if a drug is classified as a
non-formulary medication, visit the online
TRICARE Formulary Search Tool at
www.tricareformularysearch.org. For
information on how to save money and make
the most of your pharmacy benefit, visit
www.tricare.mil/pharmacy, or call
1-877-DoD-MEDS (1-877-363-6337) and
select option seven for pharmacy details.
Maternity Services
Prenatal care is important, and we strongly
recommend that those who are pregnant, and
those who anticipate becoming pregnant, seek
appropriate medical care. TRS covers maternity
care, including prenatal care, delivery, and
postpartum care. Medically necessary hospital
and professional services (prenatal and
postnatal) are covered, in addition to any other
services deemed medically necessary. Newborns
are covered separately.
Maternity Ultrasounds
TRICARE covers maternity ultrasounds when
medically necessary. Some situations that are
covered include:
• Estimating gestational age
• Evaluating fetal growth
• Conducting a biophysical evaluation for fetal
well-being
• Evaluating a suspected ectopic pregnancy
• Defining the cause of vaginal bleeding
16
• Diagnosing or evaluating multiple gestations
• Confirming cardiac activity
• Evaluating maternal pelvic masses or uterine
abnormalities
• Evaluating suspected hydatidiform mole
• Evaluating the fetus’s condition in late
registrants for prenatal care
A physician is not obligated to perform
ultrasonography on a patient who is low risk and
has no medical indications constituting medical
necessity.
Some providers may offer patients routine
ultrasound screening as part of the scope of care
after 16–20 weeks of gestation. TRICARE does
not cover routine ultrasound screening. Only
maternity ultrasounds with a valid medical
indication that constitutes medical necessity are
covered by TRICARE. Refer to your regional
contractor’s Web site for additional details on
maternity ultrasound coverage.
If your TRS coverage ends during your
pregnancy, TRICARE will not cover any
remaining maternity costs unless your family
qualifies for other TRICARE health coverage or
has enrolled in the Continued Health Care
Benefit Program. See “When TRICARE Reserve
Select Coverage Ends” in the Changes to Your
TRICARE Reserve Select Coverage section of
this handbook.
For procedures on how to add your newborn to
your TRS coverage, refer to “Coverage for
Newborns or Adopted Children” in the Changes
to Your TRICARE Reserve Select Coverage
section of this handbook.
Dental Services
The TRICARE Dental Program (TDP) is separate
from other TRICARE programs and is not
contingent upon enrollment in TRS. For more
information about the TDP, visit the United
Concordia Companies, Inc., Web site at
www.TRICAREdentalprogram.com or call
toll-free 1-800-866-8499 for general information.
To enroll, call 1-888-622-2256. If you are overseas,
call toll-free at 1-888-418-0466 or 1-717-975-5017.
Services or Procedures with Significant Limitations

Figure 2.5 is a list of medical, surgical, and behavioral health care services that may not be covered
unless exceptional circumstances exist. This list is not intended to be all-inclusive. Check your
regional contractor's Web site for additional information.

Services or Procedures with Significant Limitations Figure 2.5

Service Description
Abortions Abortions are only covered when the life of the mother would be endangered if the
pregnancy were carried to term. The attending physician must certify in writing that
the abortion was performed because a life-threatening condition existed. Medical
documentation must be provided. MTFs may not be able to provide such services
based upon limited capabilities.

COVERED SERVICES, LIMITATIONS & EXCLUSIONS

SECTION 2
Breast Pumps Heavy-duty, hospital-grade electric breast pumps (including services and supplies
related to the use of the pump) for mothers of premature infants are covered. An
electric breast pump is covered while the premature infant remains hospitalized during
the immediate postpartum period. Hospital-grade electric breast pumps may also be
covered after the premature infant is discharged from the hospital with a physician-
documented medical reason. This documentation is also required for premature infants
delivered in non-hospital settings. Breast pumps of any type, when used for reasons
of personal convenience, are excluded even if prescribed by a physician.
Cardiac and Both are covered only for certain indications. Phase III cardiac rehabilitation for
Pulmonary lifetime maintenance performed at home or in medically unsupervised settings is
Rehabilitation excluded.
Chiropractic Care Coverage is limited to ADSMs and is only available at specific MTFs under the
Chiropractic Care Program. This program is not available under TRS.
Cosmetic, Plastic, Only covered when used to restore function, correct a serious birth defect, restore body
or Reconstructive form after a serious injury, improve appearance of a severe disfigurement, or after a
Surgery medically necessary mastectomy.
Cranial Orthotic Cranial orthotic devices are excluded for treatment of nonsynostic positional
Device or Molding plagiocephaly.
Helmet
Dental Care and Both are covered only for adjunctive dental care (i.e., dental care that is medically
Dental X-Rays necessary in the treatment of an otherwise covered medical—not dental—condition).
Education and Outpatient diabetic self-management and training programs are covered when the
Training services are provided by a TRICARE-authorized individual provider who also meets
national standards for diabetes self-management education programs recognized by the
American Diabetes Association® (ADA). The provider’s “Certificate of Recognition”
from the ADA must accompany the claim for reimbursement.
Eyeglasses or Contact lenses and/or eyeglasses are covered only for:
Contact Lenses • Treatment of infantile glaucoma
• Corneal or scleral lenses for treatment of keratoconus
• Scleral lenses to retain moisture when normal tearing is not present or is inadequate
• Corneal or scleral lenses to reduce corneal irregularities other than astigmatism
• Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function
resulting from intraocular surgery, ocular injury, or congenital absence
Note: Adjustments, cleaning, and repairs for eyeglasses are not covered.

17
Services or Procedures with Significant Limitations (continued)

Service Description
Food, Food Substitutes Covered when used as the primary source of nutrition for enteral, parenteral, or oral
or Supplements, or nutritional therapy. Intraperitoneal nutrition (IPN) therapy is covered for malnutrition
Vitamins as a result of end-stage renal disease.
Gastric Bypass Gastric bypass, gastric stapling, or gastroplasty—to include vertical banded
gastroplasty—is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure and
has one of these associated medical conditions: diabetes mellitus, hypertension,
cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory
diseases), hypothalamic disorders, or severe arthritis of the weight-bearing joints.
2. The patient is 200 percent or more of the ideal weight for height and bone
structure. An associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because
of complications, requires a second surgery (a takedown).
General Anesthesia Covered when medically necessary to safeguard a patient’s life or in conjunction
Services and with non-adjunctive dental treatment (dental care not related to a medical condition)
Institutional Costs for patients with developmental, mental, or physical disabilities and for patients age
for Non-Adjunctive 5 or under.
Dental Treatment
Genetic Testing Covered when medically proven and appropriate, and when the results of the test will
influence the medical management of the patient. Routine genetic testing is not covered.
Laser/LASIK/Refractive Covered only to relieve astigmatism following a corneal transplant.
Corneal Surgery
Private Hospital Rooms Not covered unless ordered for medical reasons or a semiprivate room is not available.
Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment
system may provide the patient with a private room, but will only receive the standard
DRG amount. The hospital may bill the patient for the extra charges if the patient
requests a private room.
Shoes, Shoe Inserts, Shoe and shoe inserts are covered only in very limited circumstances. Orthopedic
Shoe Modifications, shoes may be covered when a permanent part of a brace. For individuals with diabetes,
and Arch Supports extra-depth shoes with inserts or custom-molded shoes with inserts may be covered.

Exclusions • Artificial insemination, including in-vitro

In general, TRICARE excludes services and
supplies that are not medically or psychologically
necessary for the diagnosis or treatment of a
covered illness (including behavioral health
disorders) or injury, or for the diagnosis and
treatment of pregnancy or well-baby care. All
services and supplies (including inpatient
institutional costs) related to a non-covered
condition or treatment, or provided by an
unauthorized provider, are excluded.
The following specific services are excluded
under any circumstance. This list is not
intended to be all-inclusive. Check your regional
contractor’s Web site for additional information.
• Acupuncture
• Alterations to living spaces
18
fertilization, gamete intrafallopian transfer, and
all other such reproductive technologies
• Autopsy services or postmortem examinations
• Birth control/contraceptives (non-prescription)
• Bone marrow transplants for treatment of
ovarian cancer
• Camps (e.g., weight loss)
• Care or supplies furnished or prescribed by an
immediate family member
• Charges that providers may apply to missed or
rescheduled appointments
• Counseling services that are not medically
necessary in the treatment of a diagnosed
medical condition. For example, educational
counseling, vocational counseling, and
counseling for socioeconomic purposes, stress
management, or life-style modification.
• Custodial care
• Diagnostic admissions
• Domiciliary care
• Dyslexia treatment
• Electrolysis
• Elevators or chair lifts
• Exercise equipment, spas, whirlpools, hot tubs,
swimming pools, health club memberships, or
other such charges or items
• Experimental or unproven procedures
• Foot care (routine) except if required as a result
of a diagnosed systemic medical disease affecting
the lower limbs, such as severe diabetes
• General exercise programs, even if
recommended by a physician and regardless of
whether rendered by an authorized provider
• Inpatient stays:
• For rest or rest cures
• To control or detain a runaway child,
whether or not admission is to an authorized
institution
• To perform diagnostic tests, examinations,
and procedures that could have been and are
performed routinely on an outpatient basis
• In hospitals or other authorized institutions
above the appropriate level required to
provide necessary medical care
• Learning disability services
• Megavitamins and orthomolecular psychiatric
therapy
• Mind expansion and elective psychotherapy
• Naturopaths
• Non-surgical treatment of obesity or morbid
obesity
• Personal, comfort, or convenience items, such
as beauty and barber services, radio, television,
and telephone
• Postpartum inpatient stay of a mother for
purposes of staying with the newborn infant
(usually primarily for the purpose of
breastfeeding the infant) when the infant (but
not the mother) requires the extended stay; or
continued inpatient stay of a newborn infant
primarily for purposes of remaining with the
mother when the mother (but not the newborn
infant) requires extended postpartum inpatient
stay
19
• Preventive care, such as routine annual or
employment-requested physical examinations;
routine screening procedures; immunizations;
except as provided in the Clinical Preventive
Services list (See “Clinical Preventive
Services” earlier in this section.)
• Psychiatric treatment for sexual dysfunction
• Services and supplies:
• Provided under a scientific or medical study,
grant, or research program
• Furnished or prescribed by an immediate
family member
COVERED SERVICES, LIMITATIONS & EXCLUSIONS
SECTION 2
• For which the beneficiary has no legal
obligation to pay or for which no charge
would be made if the beneficiary or sponsor
were not eligible under TRICARE
• Furnished without charge (e.g., cannot file
claims for services provided free-of-charge)
• For the treatment of obesity, except as
previously outlined in “Services or
Procedures with Significant Limitations,”
earlier in this section. Diets, weight loss
counseling, weight loss medications, wiring
of the jaw, or similar procedures are
excluded
• Inpatient stays, directed or agreed to by a
court or other governmental agency (unless
medically necessary)
• Required as a result of occupational disease
or injury for which any benefits are payable
under a worker’s compensation or similar
law, whether such benefits have been applied
for or paid, except if benefits provided under
these laws are exhausted
• That are (or are eligible to be) fully payable
under another medical insurance or program,
either private or governmental, such as
coverage through employment or Medicare
(In such instances, TRICARE is the
secondary payer for any remaining charges.)
• Sex changes or sexual inadequacy treatment.
However, treatment of ambiguous genitalia
which has been documented to be present at
birth is covered.
• Smoking cessation services and supplies
• Sterilization reversal surgery
• Surgery performed primarily for psychological
reasons (such as psychogenic)
• Therapeutic absences from an inpatient facility,
except when such absences are specifically
included in a treatment plan approved by
TRICARE
• Transportation except by ambulance
• Travel, even if prescribed by a physician, to
obtain medical care
• X-ray, laboratory, and pathological services
and machine diagnostic tests not related to a
specific illness or injury or a definitive set of
symptoms, except for cancer-screening
mammography, cancer screening, Pap tests,
and other tests allowed under the clinical
preventive services benefit.

20
Claims
Health Care Claims
In order for TRICARE to pay any provider, that
provider must be an authorized TRICARE
provider. As noted in Figure 1.1 in the Getting Care
section of this handbook, if the provider is also
participating, the provider will file claims for you.
All network providers are both TRICARE-
authorized providers and participating TRICARE
providers. If you see a TRICARE network provider
or a non-network, participating provider, your
provider will submit claims on your behalf. If you
see a non-network, non-participating provider, you
may be required to submit your own health care
claims. You will be reimbursed for TRICARE-
covered services at the TRICARE-allowable
charge, less any copayments, cost-shares, or
deductibles. Claims should be submitted to the
claims processor in the region where you live.
Note: You should ask any non-network provider if
they are participating and authorized by TRICARE.
If providers are not participating, you may incur
charges up to 15 percent above the TRICARE-
allowable charge for covered services. If providers
are not authorized by TRICARE, they will not be
paid for services rendered. If a provider would like
to become a TRICARE-authorized provider, the
regional contractor can assist them.
Claims must be filed within one year of the date
of service or within one year of the date of an
inpatient discharge. To file a claim, obtain and
fill out a Patient’s Request for Medical Payment
(DD Form 2642). You can download forms and
instructions from the TRICARE Web site at
www.tricare.mil/claims or from your regional
contractor’s Web site. You also can get forms and
instructions at a TRICARE Service Center (TSC)
or a military treatment facility (MTF). If you
have claims questions, call your regional
contractor.
21
When filing a claim, attach a readable copy of
the provider’s bill to the claim form, making sure
it contains the following:
• Social Security number of the sponsor (the
National Guard or Reserve member)
• Beneficiary (patient) name
• Provider’s name and address (If more than one
provider’s name is on the bill, circle the name
of the person who treated you.)
COVERED SERVICES, LIMITATIONS & EXCLUSIONS
SECTION 2
• Date and place of each service
• Description of each service or supply furnished
• Charge for each service
• Diagnosis (If the diagnosis is not on the bill,
be sure to complete block 8a on the form.)
Be sure to complete all 12 blocks of the form
correctly and sign it. Note: Providers submit
inpatient facility claims.
You may be required to pay up front for services if
you see a non-network, TRICARE-authorized
provider who chooses not to participate on the
claim. In this case, TRICARE will reimburse you
CLAIMS
SECTION 3
directly for the TRICARE-allowable charge minus
any applicable deductible and cost-share.
Remember that nonparticipating providers can
charge you up to 15 percent above the TRICARE-
allowable charge for services in addition to your
cost-share and/or deductible. TRICARE does not
reimburse you for this charge, and you will have to
pay the charge out of pocket.
If you receive care while traveling, file
TRICARE claims based on where you live, not
where you received care.
Regional Claims Processing Information
TRICARE North Region TRICARE South Region
Send claims to: Send claims to:
Health Net Federal Services, LLC TRICARE South Region
c/o PGBA, LLC/TRICARE Claims Department
P.O. Box 870140 P.O. Box 7031
Surfside Beach, SC 29587-9740 Camden, SC 29020-7031
www.healthnetfederalservices.com www.humana-military.com
www.myTRICARE.com www.myTRICARE.com
Send claims to the address listed for your region
in Figure 3.1. Keep a copy of your paperwork for
your records.
For claims processing information, call your
regional contractor, visit your regional
contractor’s Web site, or visit the TRICARE Web
site at www.tricare.mil/claims.
Pharmacy Claims
You may have to submit your own pharmacy
claims if you fill prescriptions at a non-network
pharmacy or if you have other health insurance
(OHI). (See “Coordinating Benefits with
Other Coverage” later in this section.) Before
reimbursement is granted for non-network
pharmacy claims, you must meet an annual
TRICARE deductible.
Claims must be filed within one year of the date
of service. To file a pharmacy claim, obtain and
fill out a Patient’s Request for Medical Payment
(DD Form 2642). Prescription claims require the
following information for each drug:
• Name of the patient
• Name, strength, date filled, days’ supply,
quantity dispensed, and price of each drug
• National Drug Code (NDC), if available
• Prescription number of each drug
• Name and address of the pharmacy
• Name and address of the prescribing physician
22
Figure 3.1
TRICARE West Region
Send claims to:
West Region Claims
P.O. Box 77028
Madison, WI 53707-1028
www.triwest.com
www.TRICARE4u.com
You can download forms and instructions at
www.tricare.mil/claims. Click on “TRICARE
Claim Form (DD Form 2642)” under “Downloads”
in the right-hand navigation column. Call
1-866-DoD-TRRX (1-866-363-8779) with
questions about filing a pharmacy claim.
Overseas Claims
TRICARE Reserve Select (TRS) claims for
services received overseas are processed under
the TRICARE South Region contract. Wisconsin
Physicians Service (WPS) has been subcontracted
by Humana Military to provide claims processing
services for all overseas TRICARE areas. For
information and assistance in filing claims for
services received overseas, visit
www.TRICARE4u.com.
Claims must be filed within one year of the date
of service or within one year of the date of an
inpatient discharge. To file a claim, obtain and
fill out a Patient’s Request for Medical Payment
(DD Form 2642). You can download forms at
www.tricare.mil/claims or from your local TSC
and a TRICARE Point of Contact (POC).
When you fill out patient information and claim
forms, be sure to use your overseas APO or FPO
mailing address and attach photocopies of fully
itemized bills from the provider showing the cost
for each service or supply provided. Using a
Continental United States (CONUS) address will
result in payment problems.
Overseas Claims Addresses
TRICARE Europe TRICARE Latin America and Canada
WPS—Overseas Claims WPS—Overseas Claims
P.O. Box 8976 P.O. Box 7985
Madison, WI 53708-8976 Madison, WI 53707-7985
Send claims to the address listed for your
overseas region in Figure 3.2. Keep a copy of
your paperwork for your records.
TRICARE Point of Contact Program
The TRICARE Overseas Program (TOP) POC
Program is a liaison service that assists
beneficiaries and host-nation providers in remote
locations in filing medical and TRICARE Dental
Program claims. This ensures timely overseas
claims filing and payment, and continued
beneficiary access to quality host-nation health
care. To locate a POC near you, contact the
TRICARE Area Office or an overseas dental
treatment facility in your area.
Coordinating Benefits with
Other Coverage
Line-of-Duty Care
TRICARE Reserve Select (TRS) does not cover
care associated with a line-of-duty injury, illness,
or disease. Line-of-duty conditions are covered
100 percent by the Department of Defense under
line-of-duty procedures separate from TRS.
Therefore, TRS deductibles and cost-shares do
not apply to care for line-of-duty conditions.
National Guard and Reserve members who have
a line-of-duty condition must have the
appropriate paperwork to receive care under line-
of-duty procedures. Any necessary care for line-
of-duty conditions must be coordinated through
your unit or Reserve Center. You will be directed
to a nearby MTF or to a TRICARE-authorized
provider for care. For more information about
obtaining line-of-duty care, contact your unit or
Reserve Center.
Other Health Insurance
TRS is the secondary payer after all health benefits
and insurance plans, except for Medicaid,
TRICARE supplements, the Indian Health Service,
23
Figure 3.2
TRICARE Pacific
WPS—Overseas Claims
P.O. Box 7985
Madison, WI 53707-7985
and other programs or plans as identified by the
TRICARE Management Activity.
If you have other health insurance (OHI), you’ll
need to follow the OHI’s rules for filing claims
and file the claim with them first. If there is an
amount your OHI does not cover, you can file
the claim with TRICARE for reimbursement. It
is important to follow the requirements of your
OHI. If your OHI denies a claim for failure to
follow their rules, such as obtaining care without
authorization or using a non-network provider,
TRICARE may also deny your claim.
Keep your regional contractor and health care
providers informed about your OHI so that they
can coordinate your benefits and help ensure that
there is no delay or denial in the payment of
your claims.
CLAIMS
SECTION 3
How TRICARE Calculates Payment
with OHI
TRICARE regulations require coordination
of benefits with OHI coverage. Due to these
regulations, TRICARE does not always pay the
OHI copayment or the balance remaining after
the OHI pays. However, your liability is usually
eliminated. Payment calculations differ by
provider status as follows.
TRICARE Network Individual/Group
Providers and Most Inpatient Facilities
If your OHI pays more than the TRICARE-
allowed amount, then no TRICARE payment is
authorized. The charge is considered paid in full,
and the provider may not bill you. Otherwise,
TRICARE pays the lesser of:
• The allowed amount minus the OHI payment
• The amount TRICARE would have paid
without OHI
• The beneficiary’s liability
(OHI copayment/deductible)
Non-Network Individual/Group Providers
Who Accept TRICARE Assignment
(Participating)
TRICARE pays the lesser of:
• The billed amount minus the OHI payment
• The amount TRICARE would have paid
without OHI
• The beneficiary’s liability
(OHI copayment/deductible)
Non-Network Individual/Group Providers
Who Do Not Accept TRICARE Assignment
(Nonparticipating)
Nonparticipating providers may only bill you up
to 15 percent above the TRICARE-allowable
charge. If your OHI paid more than 115 percent
of the TRICARE-allowable charge, then no
TRICARE payment is authorized, the charge is
considered paid in full, and the provider may not
bill you. Otherwise, TRICARE pays the lesser
of:
• 115 percent of the allowed amount minus the
OHI payment
• The amount TRICARE would have paid
without OHI
• The beneficiary’s liability (OHI
copayment/deductible)
Staff Model HMOs, Group HMOs, and
Other Capitated OHI Plan Providers
If you are enrolled in one of these OHI plans,
the provider/group either works directly for the
HMO or is paid a monthly or annual amount
rather than a fee for each service performed. In
these plans you may only receive a copayment
receipt, and an itemized bill or explanation of
benefits (EOB) may not be available.
In these cases, you can submit a Patient’s
Request for Medical Payment (DD Form 2642)
with a copy of your HMO copayment receipt.
For processing, the copayment is considered the
billed amount. Deductibles and cost-shares are
applied, and you may only receive partial
reimbursement of your HMO copayment.
24
Pharmacy Claims
When using OHI, the OHI is the first payer for
pharmacy coverage. You may then be eligible for
full or partial reimbursement from TRICARE for
out-of-pocket costs, including copayments. If
you have OHI, you should use a retail pharmacy
under your private insurer that is also in the
TRICARE retail pharmacy network to avoid
paying the TRICARE non-network deductible.
You may not use TRICARE’s mail-order
pharmacy if you have OHI prescription drug
coverage, unless the medication is not covered
under the other plan, or unless you exceed the
dollar limit of coverage under the other plan.
When you have OHI, the rules of that insurer
apply. You should call 1-866-DoD-TRRX
(1-866-363-8779) for specific instructions about
filing pharmacy claims if you have OHI.
Third-Party Liability
The Federal Medical Care Recovery Act allows
TRICARE to be reimbursed for its costs of
treatment if you are injured in an accident that
was caused by someone else. The Statement of
Personal Injury Third Party Liability (DD Form
2527) form will be sent to you if a claim appears
to have third-party liability involvement. Within
35 calendar days you must complete and sign
this form and follow the directions for returning
it to the appropriate claims processor. You can
download the DD Form 2527 at
www.tricare.mil/claims or from your regional
contractor’s Web site.
Explanation of Benefits
An EOB is not a bill. It is an itemized statement
that shows what action TRICARE has taken on
your claims. An EOB is for your information and
files.
After reviewing the EOB, you have the right to
appeal certain decisions regarding your claims and
must do so in writing within 90 days of the date of
the EOB notice. (For more information about
appeals, see the Information and Assistance section
of this handbook.) You should keep EOBs with
your health insurance records for reference.
For a sample of the EOB in your region along
with instructions for reading the EOB, see the
following figures in the Appendix section of this
handbook:
• North Region: Figure 8.1
• South Region: Figure 8.2
• West Region: Figure 8.3

CLAIMS
SECTION 3

25
Changes to Your TRICARE Reserve
Select Coverage
Changes to Your Coverage
When you experience a change in your family
composition certain actions are necessary to
ensure continuous TRICARE Reserve Select
(TRS) coverage for all eligible family members.
Examples of changes in family composition
include:
• Marriage
• Birth or adoption of child
• Placement of a child in the legal custody of the
National Guard or Reserve member by an
order of the court
• Divorce or annulment
• Death of a spouse or family member
• Last family member becomes ineligible
(requires a change from TRS member-and-
family to TRS member-only coverage)
To ensure there is no interruption to your TRS
coverage, first, you must report the change in
family composition as described in “Updating
DEERS” in the Information and Assistance
section of this handbook.
Second, you must log on to the TRS Web
application at
https://www.dmdc.osd.mil/appj/trs/index.jsp and
follow the prompts for making changes to family
composition. Print the TRS Request form from the
TRS Web application, sign it, and send it to your
TRICARE regional contractor. This form must be
postmarked or received by your regional contractor
no later than 60 days from the date of the family
change. The effective date of coverage is the date
the family change occurred.
When a change is processed that alters the
premium amount (e.g., a change from member-
only to member-and-family coverage), the
effective date of the premium change will be the
date the family change occurred.
26
Coverage for Newborns or
Adopted Children
TRS coverage for newborns or adopted children
differs depending on the type of coverage the
sponsor (the National Guard or Reserve
Member) has: TRS member-and-family or TRS
member-only.
Adding a Newborn or Adopted Child
to Existing Member-and-Family
Coverage
With TRS member-and-family coverage,
newborns and adopted children are covered
automatically by TRS for 60 days after the birth
or adoption. Children can continue TRS with no
break in coverage if the TRS Request form is
postmarked or received by the TRICARE Service
Center (TSC) or the regional contractor within
60 days of the birth or adoption. Beyond 60
days, the child must be enrolled for claims to be
paid. If the TRS Request form is not received by
the TSC or the regional contractor or postmarked
within 60 days, any further TRS coverage for the
child is terminated. All pended claims will be
denied, and the member is responsible to pay the
total amount for all health care the child received.
Note: Since a family plan already exists,
additional premiums will not be required when
enrolling the new child.
Adding a Newborn or Adopted Child
When You Have Member-Only
Coverage
With TRS member-only coverage, newborns or
adopted children are not automatically covered
and claims will not be paid until the newborn or
adopted child is registered in DEERS and a TRS
Request form is received. If the member wants
coverage retroactive to the date of the birth or
adoption, the request for member-and-family
coverage must be received by the TSC or the
regional contractor or postmarked within 60
days of the birth or adoption. If the TRS
Request form is not received by the TSC or
the regional contractor or postmarked within 60
days, all pended claims will be denied, and the
member is responsible to pay the total amount
for all health care the child received.
Note: When the type of plan changes from
memberonly to memberandfamily, there is an
increase in the monthly premium. The sponsor is
responsible for paying the increase in premium,
which begins on the date of the birth or adoption.
When TRICARE Reserve Select
Coverage Ends
TRS coverage may be terminated for a number
of reasons. When TRS coverage is terminated,
the regional contractors will initiate your
premium payment refund process within 10 days
of receiving a written TRS termination request.
When your TRS coverage is terminated for any
reason, your family members’ coverage
automatically ends as well.
Loss of Eligibility
Sponsors or family members may lose eligibility
for TRS coverage for the following reasons.
Note: This list is not allinclusive.
• Sponsor or family member becomes eligible
for, or covered under, the Federal Employees
Health Benefits program
• Sponsor leaves the Selected Reserve
• Divorce
• Child reaches age 21 (or 23 if enrolled as a
fulltime student in college)
Eligibility for Other TRICARE
Coverage
You may become eligible for other TRICARE
coverage at any time. If you become eligible for
other TRICARE coverage for a period of 30 days
or less, TRS coverage will continue unchanged.
If you become eligible for other TRICARE
coverage for a period of more than 30
consecutive days, TRS coverage will terminate.
Other TRICARE coverage may include coverage
before (early eligibility), during (active duty
coverage), and after (Transitional Assistance
27
Management Program or TAMP) periods of
activation. Any premium amounts already paid
for periods beyond the termination date will be
refunded as described previously. If you, the
National Guard or Reserve member, become
eligible for other TRICARE coverage through a
family member, then you as the sponsor, as well
as any TRSenrolled family members, may
terminate TRS coverage without incurring a
lockout.
Additionally, if you become eligible for one of
the programs listed below, your TRS coverage
will be terminated.
• CHAMPVA
• Another federally sponsored health benefits
program, such as the Federal Employees
Health Benefits program.
It is important to note that TRS coverage will
not automatically resume after other
TRICARE coverage ends. If you want to enroll
for TRS coverage at that time, you must follow
the procedures to qualify for and purchase TRS
coverage again, the same as any beneficiary
purchasing new coverage.
Voluntary Termination
You may request to terminate TRS coverage at
any time. If you want to terminate coverage, do
not just stop making payments. You must take
the following action to end your TRS coverage:
• Log on to the Guard and Reserve Web Portal at
https://www.dmdc.osd.mil/appj/trs/index.jsp.
• Complete the TRS Request form.
• Print, sign, and mail your completed TRS
Request form to your regional contractor.
A oneyear TRS purchase lockout will apply
CHANGES TO YOUR TRS COVERAGE
SECTION 4
to members who voluntarily terminate TRS
coverage. A purchase lockout means you will
not be able to purchase TRS coverage for one
year from the effective date of termination. If
you do not take action to terminate coverage and
you simply stop making premium payments,
your coverage terminates. However, you are still
responsible for any premium amounts that were
due prior to the date you were officially
terminated from TRS.
Termination Due to Non-Payment
Your payment is due no later than the last day of
each month. Your payment will apply to the
following month of coverage. Failure to pay
monthly premiums on time will result in
termination of coverage, but you must still
pay any overdue amounts. (This may result in
up to two months or more of overdue premium
payments.) Termination of coverage due to non-
payment will result in a TRS purchase lockout
for one year or until overdue premiums are paid
in full, whichever is longer.
Note: The government pursues collection action for
overdue and delinquent premiums and may notify
your commander and collect these amounts from
your National Guard or Reserve pay.
Certificate of Creditable Coverage
When your TRS coverage ends, you will receive a
certificate of creditable coverage. The certificate of
creditable coverage is a document that serves as
evidence of prior health care coverage under
TRICARE so that you cannot be excluded from a
new health plan for pre-existing conditions.
The Defense Manpower Data Center Support
Office (DSO) will issue a certificate of creditable
coverage to sponsors and family members upon
loss of eligibility. Certificates reflect the most
recent period of continuous coverage under
TRICARE.
Certificates issued upon request of a beneficiary
reflect each period of continuous coverage under
TRICARE that ended within the 24 months prior
to the date of loss of eligibility. Each certificate
identifies the name of the sponsor or family
member for whom it is issued, the dates
TRICARE coverage began and ended, and the
certificate issue date.
28
Send your written requests for a certificate of
creditable coverage to the DSO at:
Defense Manpower Data Center
Support Office
Attn: Certificate of Creditable Coverage
400 Gigling Road
Seaside, CA 93955-6771
The request must include:
• Sponsor’s name and Social Security number
• Name of person for whom the certificate is
requested
• Reason for the request
• Name and address to whom and where the
certificate should be sent
• Requester’s signature
You cannot request a certificate by phone. If
there is an urgent need for a certificate of
creditable coverage, fax your request to the DSO
at 1-831-655-8317 and/or request that the DSO
fax the certificate to a particular number.
For more information, contact the DSO at
1-800-538-9552. For TTY/TDD, dial
1-866-363-2883. You may send questions via
e-mail to the TRICARE Management Activity
Office of HIPAA Electronic Standards at
hipaamail@tma.osd.mil or visit
www.tricare.mil/certificate.
Continued Health Care Benefit
Program
Once your eligibility under TRS ends, you may
be able to apply for temporary, transitional
medical coverage under the Continued Health
Care Benefit Program (CHCBP). CHCBP is a
premium-based health care program and is
similar to, but not part of, TRICARE. If you
qualify, you must enroll yourself and your
eligible family members in CHCBP within 30
days after termination of TRS coverage. Benefits
under CHCBP are virtually the same as those
under TRS. To find out if you are eligible for
CHCBP, contact the program administrator,
Humana Military, at 1-800-444-5445 or visit
www.humana-military.com.
 • If TRS member-only coverage is in effect on
the date of the member’s death, the coverage
will terminate effective on the date of death.
Eligible family members may purchase TRS
survivor coverage within 60 days after the date
of death by submitting a TRS Request form.
The request must be received by the TSC or
regional contractor or postmarked no later
than 60 days after the date of the member’s
death. Surviving family members will receive
letters advising them of their option to
purchase coverage, as well as instructions
for accessing the TRS Request form.

TRICARE Reserve Select

Survivor Coverage

If a National Guard or Reserve member is

covered by TRS on the day of his or her death,
surviving family members may purchase or
continue coverage for an additional six months
beyond the date of the member’s death. The
effective date of coverage is the day after the
date of death. Surviving family members are
responsible for paying applicable monthly
premiums. Two scenarios apply depending on
the type of coverage in effect at the time of the
member’s death.

• If TRS member-and-family coverage is in

effect on the date of the member’s death,
DEERS will automatically convert your TRS
member-and-family coverage to TRS survivor
coverage. DEERS will also establish an end
date for eligibility six months from the date of
the member’s death. Surviving family members
CHANGES TO YOUR TRS COVERAGE
SECTION 4

will receive letters advising them of their

coverage and their option to terminate,
if desired.

29
Information and Assistance
Qualifying for TRICARE
Reserve Select
For information or assistance with qualifying for
and purchasing TRICARE Reserve Select (TRS),
contact your Service personnel office.
• Reserve Affairs Web site:
www.defenselink.mil/ra
• Guard and Reserve Web Portal:
https://www.dmdc.osd.mil/appj/trs/index.jsp
Customer Service
Contact your regional contractor, or TRICARE
Area Office if overseas, for information or
assistance with purchasing TRS coverage,
premium billing and payment collection,
obtaining health care services, health care
claims, or covered benefits. Refer to pages 2–3
of this handbook for a list of regional contractor
telephone numbers and Web addresses.
Beneficiary Counseling and
Assistance Coordinators
Beneficiary counseling and assistance
coordinators (BCACs) can help you with
TRICARE and Military Health System inquiries
and concerns, and can advise you about
obtaining health care. BCACs are located at
military treatment facilities (MTFs) and at the
TRICARE Regional Offices (TROs).
Each of the three TROs has a special National
Guard and Reserve BCAC available to assist you
with specific TRICARE questions or concerns you
may have as a National Guard or Reserve member
or family member. A National Guard and Reserve
BCAC located in the Washington, D.C. area serves
all overseas areas. To locate a BCAC near you, visit
www.tricare.mil/bcacdcao for an online directory.
www.tricare.mil
For more information about your TRICARE
benefits and how they change during periods of
activation and deactivation, visit the TRICARE
Web site at www.tricare.mil. Once you have
30
entered your profile, you can explore the plan
you are using and see how the benefits change
when you are activated, deactivated, and deployed.
Updating DEERS
To register family members or to update their
records, you must complete the Application for
Department of Defense Common Access Card and
DEERS Enrollment, (DD Form 1172) and provide
other important documentation such as marriage,
birth or death certificates; family members’ Social
Security numbers; DD 214s (separation papers
from active duty); Medicare cards; etc. You must
update each family member’s eligibility record
separately when changes occur.
You or a family member should contact the
nearest uniformed services identification (ID)
card-issuing facility to find out what documents
you need in order to register or update eligibility
information in DEERS. You can find the closest
facility at www.dmdc.osd.mil/rsl/owa/home. If
family members reside at a different address, the
sponsor must have the DD Form 1172 notarized.
You can verify DEERS information by
contacting your regional contractor’s toll-free
number, a TRICARE Service Center, or a BCAC
at your local MTF.
DEERS can be updated using one of the
following methods:
• Visit a local uniformed services ID
card-issuing facility. Locate one at
www.dmdc.osd.mil/rsl/owa/home.
• Call the Defense Manpower Data Center
Support Office at 1-800-538-9552.
(Monday–Thursday from 6 a.m. to 3:30 p.m.
Pacific Time, except Federal holidays)
• Fax changes to DEERS at 1-831-655-8317.
• Mail changes to:
Defense Manpower Data Center
Support Office
Attn: COA
400 Gigling Road
Seaside, CA 93955-6771
 INFORMATION AND ASSISTANCE
SECTION 5
Appealing a Decision Appeal Requirements
Your appeal must meet the requirements listed in
If you believe a service or claim was improperly Figure 5.1.
denied, in whole or in part, you (or another
appropriate party) may file an appeal. An appeal Filing an Appeal
must involve an appealable issue. For example,
Appeals must be filed with your regional
you have the right to appeal TRICARE decisions
contractor within specific deadlines. If you are
regarding the payment of your claims. You also
not satisfied with a decision rendered on an
may appeal the denial of a requested authorization
appeal, there are further levels of appeal. For
of services, even though no care has been provided
specific information about filing an appeal in
and no claim submitted.
your region, contact your regional contractor.
There are some things you may not appeal. For
Prior-authorization-denial appeals may either be
example, you may not appeal the denial of
expedited or non-expedited, depending on the
services from an unauthorized provider.
urgency of the situation. You or an appointed
representative must file an expedited appeal
When services are denied based on a medical
within three calendar days after receipt of the
necessity or a benefit decision, you are notified
initial denial. A non-expedited review of a denial
automatically in writing. The notification will
must be filed no later than 90 days after receipt
include an explanation of what was denied or
of the initial denial.
why a payment was reduced and the reasoning
behind that decision.

TRICARE Appeal Requirements Figure 5.1

An appropriate appealing party must submit the appeal. Proper appealing parties include:
• You, the beneficiary
• Your custodial parent (if you are a minor) or your guardian
• A person appointed in writing by you to represent you for the purpose of the appeal

1 • An attorney filing on your behalf

• Non-network participating providers
If a physician or other party is going to submit the appeal, you must complete and sign an Appointment
of Representative and Authorization to Disclose Information form, which is available on your regional
contractor’s Web site. If the appeal is submitted without this form, it will not be processed.
Note: Network providers are not appropriate appealing parties (unless appointed by you in writing).
The appeal must be in writing. See the addresses in Figure 5.2 on the following page for submitting
2 different types of appeals.
The issue in dispute must be an appealable issue. The following are non-appealable issues:
• Allowable charges
• Eligibility
3 • Denial of nonavailability statements (NAS) for inpatient behavioral health care
• Denial of services from an unauthorized provider
• Denial of treatment plan when an alternative treatment plan is selected
The appeal must be filed in a timely manner. An appeal must be filed within 90 days after the date on
4 the EOB or denial notification letter.
There must be an amount in dispute to file an appeal. In an appeal case involving denial of an
authorization in advance of receiving the actual services, the amount in dispute is deemed to be the
5 estimated TRICARE-allowable charge for the services requested. There is no minimum disputed
amount necessary to request reconsideration.

31
Appeals should contain the following
information:
• Beneficiary’s name, address, and telephone
number
• Sponsor’s Social Security number (SSN)
• Beneficiary’s date of birth
• Beneficiary’s or appealing party’s signature
A description of the issue or concern must
include:
Filing a Grievance
A grievance is a written complaint or concern
dealing with a non-appealable issue regarding a
perceived failure by any member of the health
care delivery team—including TRICARE-
authorized providers, military providers, a
TRICARE contractor, or subcontractor
personnel—to provide appropriate and timely
health care services, access, or quality, or to
deliver the proper level of care or service.

• The specific issue in dispute
• A copy of the previous denial determination
notice
• Any appropriate supporting documents
Send your appeal to your regional contractor. See
Figure 5.2 for details.
The grievance process allows full opportunity to
report in writing any concern or complaint
regarding health care quality or service. Any
TRICARE civilian or military provider,
TRICARE beneficiary, sponsor, parent or
guardian, or other representative of an eligible
dependent child may file a grievance. Your
regional contractor is responsible for the
investigation and resolution of all grievances.
Grievances are resolved no later than 60 days
from receipt. Following resolution, the party who
submitted the grievance will be notified of the
review and resolution.

Regional Appeals Filing Information Figure 5.2

TRICARE North Region TRICARE South Region TRICARE West Region

Claims Appeals:
Health Net Federal Services, LLC
c/o PGBA LLC/TRICARE
Claims Appeals
P.O. Box 870148
Surfside Beach, SC 29587-9748
Claims Appeals Fax:
1-888-458-2554
Prior Authorization Appeals:
Health Net Federal Services, LLC
c/o PGBA, LLC/TRICARE
Authorization Appeals
P.O. Box 870142
Surfside Beach, SC 29587-9742
Prior Authorization Appeals Fax:
1-888-881-3622
Claims Appeals: Claims Appeals:
TRICARE South Region Appeals TriWest Healthcare Alliance Corp.
P.O. Box 202002 Claims Appeals
Florence, SC 29502-2002 P.O. Box 86508
Prior Authorization Appeals: Phoenix, AZ 85080
Prior Authorization Appeals:
Humana Military Healthcare
Services, Inc. TriWest Healthcare Alliance Corp.
Attn: Clinical Appeals Claims Appeals
P.O. Box 740044 P.O. Box 86508
Louisville, KY 40201-9973 Phoenix, AZ 85080
Behavioral Health Appeals:
ValueOptions Behavioral Health
Attn: Appeals and Reconsideration
Department
P.O. Box 551138
Jacksonville, FL 32255-1138

32

Grievances may include such issues as:
• The quality of certain aspects of health care or
services, such as accessibility, appropriateness,
level, continuity or timeliness of care;
effectiveness; or outcome
• The demeanor or behavior of providers and
their staff
• The performance of any part of the health care
delivery system
• Practices related to patient safety
When filing a grievance, include the following
INFORMATION AND ASSISTANCE
SECTION 5
• Beneficiary’s date of birth
• Beneficiary’s signature
• A description of the issue or concern,
including:
• The date and time of the event
• Name of the provider(s) and/or person(s)
involved
• Location of the event (address)
• The nature of the concern or complaint
• Details describing the event or issue
• Any appropriate supporting documents

ACRONYMS
SECTION 6
information:
File your grievance with your regional
• The beneficiary’s name, address, and telephone contractor. See Figure 5.3 for details.
number
• Sponsor’s SSN

Filing a Grievance Figure 5.3

TRICARE North Region TRICARE South Region TRICARE West Region

Submit your grievance in writing to:
Health Net Federal Services, LLC
c/o PGBA, LLC/TRICARE Grievance
P.O. Box 870150
Surfside Beach, SC 29587-9750
Submit online at:
www.healthnetfederalservices.com
Submit by fax:
1-888-317-6155
Submit your grievance in Submit your grievance in
writing to: writing to:
Regional Grievance Coordinator TriWest Healthcare Alliance Corp.
Humana Military Healthcare Attn: Customer Relations Dept.
Services, Inc. P.O. Box 86036
8123 Datapoint Drive, Suite 400 Phoenix, AZ 85080
San Antonio, TX 78229
For behavioral health care
concerns, send your
information to:
Grievance Specialist
ValueOptions
P.O. Box 551188
Jacksonville, FL 32255-1188

33
Reporting Suspected Fraud and
Abuse
Fraud happens when a person or organization
deliberately deceives others to gain some sort of
unauthorized benefit or compensation. Health
care abuse occurs when providers supply
services or products that are medically
unnecessary or that do not meet professional
standards.
You are an important partner in the ongoing fight
against fraud and abuse, and your most effective
tool is your explanation of benefits (EOB).
Since an EOB is a tangible statement of
services/supplies received, it is one of the first
lines of defense against health care fraud. Each
EOB provides a toll-free number to call if you
have questions about services you believe are
billed fraudulently. You also can access the
TRICARE Program Integrity Web site at
www.tricare.mil/fraud for direct links to each
contractor’s fraud and abuse reporting office.
We strongly encourage you to read your EOBs
carefully.
Report suspected fraud and abuse to your
regional contractor. See Figure 5.4 for details.
Report pharmacy program fraud or abuse by
calling 1-800-332-5455. You also can report any
fraud or abuse issues directly to TRICARE at
fraudline@tma.osd.mil.

Reporting Fraud and Abuse Figure 5.4

TRICARE North Region TRICARE South Region TRICARE West Region

• Call 1-800-977-6761
• Send an e-mail message to:
program_integrity@health.net
• Report online at
www.healthnetfederalservices.com
• Mail information to:
Health Net Federal Services, LLC
Attn: Program Integrity
P.O. Box 870147
Surfside Beach, SC 29587-9747
• Call 1-800-333-1620 • Call 1-888-584-9378
• Report online at • Fax 1-602-564-2171
www.humana-military.com
• Report online at
• Mail information to: www.triwest.com
Humana Military Healthcare
Services, Inc.
Attention: Program Integrity
500 West Main St., 19th floor
Louisville, KY 40202

34
Acronyms
ADA American Diabetes Association
BCAC Beneficiary Counseling and
Assistance Coordinator
CHCBP Continued Health Care Benefit
Program
DEERS Defense Enrollment Eligibility
Reporting System
DME Durable Medical Equipment
DoD Department of Defense
DRG Diagnosis-related Group

ACRONYMS
SECTION 6
DSO Defense Manpower Data Center
Support Office
ECHO Extended Care Health Option
EOB Explanation of Benefits
MTF Military Treatment Facility
NDC National Drug Code
OHI Other Health Insurance
POC Point of Contact
RTC Residential Treatment Center
SNF Skilled Nursing Facility
SSN Social Security Number
TAMP Transitional Assistance
Management Program
TAO TRICARE Area Office
TDP TRICARE Dental Program
TGRO TRICARE Global Remote
Overseas
TLAC TRICARE Latin America and
Canada
TOP TRICARE Overseas Program
TPR TRICARE Prime Remote
TPRADFM TRICARE Prime Remote for
Active Duty Family Members
TRO TRICARE Regional Office
TRS TRICARE Reserve Select
TSC TRICARE Service Center
USFHP US Family Health Plan
WPS Wisconsin Physicians Service

35
Glossary
Balance Billing
A term used to describe instances when a
provider bills a beneficiary for the difference
between billed charges and the TRICARE-
allowable charge after TRICARE (and other
health insurance) has paid everything it’s going
to pay. Participating providers are prohibited
from balance billing. Nonparticipating
providers may charge up to 15 percent above
the TRICARE-allowable charge.
Beneficiary Counseling and Assistance
Coordinator (BCAC)
Persons at military treatment facilities and
TRICARE Regional Offices who are
available to answer questions, help solve
health care-related problems, and assist
beneficiaries in obtaining medical care
through TRICARE. To locate a BCAC, visit
www.tricare.mil/bcac.
Catastrophic Cap
The maximum amount TRICARE
beneficiaries are required to pay out of pocket
for deductibles and cost-shares each federal
fiscal year (October 1–September 30). The
cap applies to all TRICARE-covered services
based on TRICARE-allowable charges.
Monthly premium payments and payments for
non-covered services are not credited toward
the catastrophic cap.
Continued Health Care Benefit
Program (CHCBP)
A premium-based health care program you
may purchase after the loss of TRICARE
eligibility if you qualify. The CHCBP offers
temporary transitional health coverage and
must be purchased within 30 days after
TRICARE eligibility ends.
Covered Family Member
An eligible family member (see “Eligible
Family Member” definition on this page)
enrolled in TRICARE Reserve Select.
Contingency Operation
“A military operation that (a) results in the
call or order to, or retention of, active duty of
members of the uniformed services under
36
section 688, 12301 (b), 12302, 12304,
12305, or 12406 of this title [10], chapter 15
of this title [10], or any other provision of
law during a war or during a national
emergency declared by the President or
Congress.” Written calls or orders to active
duty will specify if they are in support of a
contingency operation.
Cost-share
A cost-share is the percentage or portion of
costs that the beneficiary will pay for
inpatient or outpatient care.
Deductible
The annual amount a TRICARE Reserve
Select beneficiary must pay for covered
outpatient benefits before TRICARE begins
to share costs.
Defense Enrollment Eligibility
Reporting System (DEERS)
A database of uniformed services members
(sponsors), family members, and others
worldwide who are entitled under law to
military benefits, including TRICARE.
Beneficiaries are required to keep DEERS
updated. DEERS is the official system of
record for TRICARE eligibility.
Eligible Family Member
Spouse, child, or unmarried person as
specified in 10USC1072 (2)(A), (D), & (I)
quoted below.
(A) spouse;
(D) a child who:
(i) has not attained the age of 21;
(ii) has not attained the age of 23, is
enrolled in a full-time course of study at an
institution of higher learning approved by
the administering Secretary and is, or was at
the time of the member’s or former member’s
death, in fact dependent on the member or
former member for over one-half of the
child’s support; or
(iii) is incapable of self-support because
of a mental or physical incapacity that
occurs while a dependent of a member or
former member under clause (i) or (ii) and
is, or was at the time of the member’s or
former member’s death, in fact dependent on
the member or former member for over one-
half of the child’s support;
(I) an unmarried person who:
(i) is placed in the legal custody of the
member or former member as a result of an
order of a court of competent jurisdiction in
the United States (or a Territory or
possession of the United States) for a period
of at least 12 consecutive months;
(ii) either:
(I) has not attained the age of 21;
(II) has not attained the age of 23
and is enrolled in a full-time course of study
at an institution of higher learning approved
by the administering Secretary; or
(III) is incapable of self support
because of a mental or physical incapacity
that occurred while the person was
considered a dependent of the member or
former member under this subparagraph
pursuant to subclause (I) or (II);
(iii) is dependent on the member or
former member for over one-half of the
person’s support;
(iv) resides with the member or former
member unless separated by the necessity of
military service or to receive institutional
care as a result of disability or
incapacitation or under such other
circumstances as the administering Secretary
may by regulation prescribe; and
(v) is not a dependent of a member
or a former member under any other
subparagraph.
Explanation of Benefits (EOB)
A statement sent to beneficiaries showing
that claims were processed and the amount
paid to providers. If denied, an explanation
of denial is provided. (Refer to the Appendix
section for samples of EOB statements.)
Military Treatment Facility (MTF)
A medical facility (hospital, clinic, etc.)
owned and operated by the uniformed
services usually located on or near a military
base.
Negotiated Rate
The rate network providers and participating
non-network providers have agreed to accept
for covered services.
37
Network Provider (also known as
TRICARE Network Provider)
TRICARE network providers have signed an
agreement with your regional contractor to
provide care at a negotiated rate. Network
providers handle claims for you.
Non-network Provider
Non-network, TRICARE-authorized
providers have not signed an agreement with
your regional contractor and are therefore
“out of network.” There are two types of
non-network providers: participating and
nonparticipating.
Nonparticipating Non-network
Provider
Nonparticipating, non-network, TRICARE-
authorized providers have not agreed to
accept the TRICARE-allowable charge or
file your claims. Nonparticipating providers
may charge you up to 15 percent above the
TRICARE-allowable charge for services.
This amount is your responsibility and will
not be shared by TRICARE.
Other Health Insurance (OHI)
Any non-TRICARE health insurance that is
GLOSSARY
SECTION 7
not considered a supplement acquired
through an employer, entitlement program,
or other source. TRICARE pays second after
all other health plans except for Medicaid,
TRICARE supplements, the Indian Health
Service, or other programs or plans as
identified by the TRICARE Management
Activity.
Participate on a Claim
When TRICARE-authorized providers
participate on a claim, also known as
“accepting assignment,” they agree to file
the claim for you, to accept payment directly
from TRICARE, and to accept the amount
APPENDIX
SECTION 8
of the TRICARE-allowable charge, less any
applicable patient cost-share paid by you,
as payment in full for their services.
Participating Non-network Provider
Participating providers have agreed to file
claims for you, to accept payment directly
from TRICARE, and to accept the
TRICARE-allowable charge, less any
applicable patient cost-shares paid by you,
as payment in full for their services. TRICARE Supplement
Providers may participate on a claim-by- A health plan you may purchase specifically
claim basis, meaning they may choose to to supplement your TRICARE Reserve
participate on one claim, but not another. Select coverage. It will pay second after
TRICARE. Employer-sponsored health
Prior Authorization insurance is not considered a TRICARE
A process of reviewing certain medical, supplement.
surgical, and behavioral health services to
ensure medical necessity and appropriateness
of care prior to services being rendered or
within 24 hours of an emergency admission.
Visit your TRICARE regional contractor's
Web site for a list of services that require
prior authorization.

Regional Contractor
A TRICARE civilian partner who provides
health care services and support in the
TRICARE regions (Health Net Federal
Services, LLC; Humana Military Healthcare
Services, Inc.; and TriWest Healthcare
Alliance Corp.).

Transitional Assistance Management

Program (TAMP)
Transitional health care for certain
uniformed services members (and eligible
family members) who separate from active
duty.

TRICARE-allowable Charge
The maximum amount TRICARE will pay
for services.

TRICARE-authorized Provider
A provider who meets TRICARE’s licensing
and certification requirements and has been
certified by TRICARE to provide care to
TRICARE beneficiaries. If you see a
provider who is not TRICARE-authorized
and can never be certified, you are
responsible for the full cost of care.
TRICARE-authorized providers include
doctors, hospitals, ancillary providers
(laboratories and radiology centers), and
pharmacies. There are two types of
TRICARE-authorized providers: network
and non-network.

TRICARE Network Provider

See Network Provider

38
Appendix
Sample Explanation of Benefits
Statements

The following pages list figures and reference

details for each regional contractor’s explanation
of benefits (EOB) statements.
• North Region: Figure 8.1
• South Region: Figure 8.2
• West Region: Figure 8.3

APPENDIX
SECTION 8

39
North Region Explanation of Benefits Statement Sample Figure 8.1

40
How to Read Your TRICARE EOB for
the North Region
1. PGBA, LLC—PGBA processes all
TRICARE claims for the region where you
live.
2. Regional Contractor—The name “Health
Net Federal Services” and the Health Net
logo will appear here.
3. Date of Notice—PGBA prepared your
TRICARE EOB on this date.
4. Sponsor SSN/Sponsor Name—We process
your claim using the Social Security number
of the military service member (active duty,
retired, National Guard, Reserve, or
deceased) who is your TRICARE sponsor.
5. Beneficiary Name—The patient who
received medical care and for whom this
claim was filed.
6. Mail-to Name and Address—We mail the
TRICARE EOB directly to the patient (or
patient’s parent or guardian) at the address
given on the claim. (Note: Be sure your
doctor has updated your records with your
current address.)
7. Benefits Were Payable To—This field will
appear only if your doctor accepts
assignment. This means the doctor accepts
the TRICARE maximum allowable charge as
payment in full for the services you received.
8. Claim Number—We assign each claim a
unique number. This helps us keep track of
the claim as it is processed. It also helps us
find the claim quickly whenever you call or
write us with questions or concerns.
9. Service Provided By/Date of Services—
This section lists who provided your medical
care, the number of services and the
procedure codes, as well as the date you
received the care.
10. Services Provided—This section describes
the medical services you received and how
many services are itemized on your claim.
It also lists the specific procedure codes that
doctors, hospitals, and labs use to identify
the specific medical services you received.
11. Amount Billed—Your doctor, hospital, or
lab charged this fee for the medical services
you received.
12. TRICARE Approved—This is the amount
TRICARE approves for the services you
received.
41
13. See Remarks—If you see a code or a
number here, look at the Remarks section
(18) for more information about your claim.
14. Claim Summary—Here we give you a
detailed explanation of the action we took on
your claim. You will find the following totals:
amount billed, amount approved by
TRICARE, non-covered amount, amount
(if any) that you have already paid to the
provider, amount your primary health
insurance paid (if TRICARE is your
secondary insurance), benefits we have paid
to the provider, and benefits we have paid to
the beneficiary. A Check Number will appear
here only if a check accompanies your EOB.
15. Beneficiary Liability Summary—You may
be responsible for a portion of the fee your
doctor has charged. If so, you’ll see that
amount itemized here. It will include any
charges that we have applied to your annual
deductible and any cost-share or copayment
you must pay.
16. Patient Responsibility—The total amount
you owe for this claim.
17. Benefit Period Summary—This section
shows how much of the individual and family
annual deductible and maximum
out-of-pocket expense you have met to date.
We calculate your annual deductible and
maximum out-of-pocket expense by fiscal
year. See the Fiscal Year beginning date in
this section for the first date of the fiscal
year.
18. Remarks—Explanations of the codes or
numbers listed in See Remarks will appear
here.
19. Toll-Free Telephone Number—Questions
about your TRICARE explanation of
benefits? Please call PGBA toll-free at
1-877-TRICARE (1-877-874-2273). Our
professional customer service representatives
will gladly assist you.
APPENDIX
SECTION 8
South Region Explanation of Benefits Statement Sample Figure 8.2

42
How to Read Your TRICARE EOB for
the South Region
1. PGBA, LLC—PGBA processes all
TRICARE claims for the region where you
live.
2. Regional Contractor—The name “Humana
Military” and the Humana Military logo will
appear here.
3. Date of Notice—PGBA prepared your
TRICARE EOB on this date.
4. Sponsor SSN/Sponsor Name—We process
your claim using the Social Security number
(SSN) of the military service member (active
duty, retired, or deceased) who is your
TRICARE sponsor. For security reasons,
only the last four digits of your sponsor’s
SSN will appear on the EOB.
5. Beneficiary Name—The patient who
received medical care and for whom this
claim was filed.
6. Mail-to Name and Address—We mail the
EOB directly to the patient (or patient’s
parent or guardian) at the address given on
the claim. (Note: Be sure your doctor has
updated your records with your current
address.)
7. Benefits Were Payable To—This field will
appear only if your doctor accepts
assignment. This means the doctor accepts
the TRICARE allowable charge as payment
in full for the services you received.
8. Claim Number—We assign each claim a
unique number. This helps us keep track of
the claim as it is processed. It also helps us
find the claim quickly whenever you call or
write us with questions or concerns.
9. Service Provided By/Date of Services—
This section lists who provided your medical
care, the number of services, and the
procedure codes, as well as the date you
received the care.
10. Services Provided—This section describes
the medical services you received and how
many services are itemized on your claim. It
also lists the specific procedure codes that
doctors, hospitals, and labs use to identify the
specific medical services you received.
11. Amount Billed—Your doctor, hospital, or
lab charged this fee for the medical services
you received.
43
12. TRICARE Approved—This is the amount
TRICARE approves for the services you
received.
13. See Remarks—If you see a code or a
number here, look at the Remarks section
(17) for more information about your claim.
14. Claim Summary—Here we give you a
detailed explanation of the action we took
on your claim. You will find the following
totals: amount billed, amount approved by
TRICARE, non-covered amount, amount
that you have already paid to the provider
(if any), amount your primary health
insurance paid (if TRICARE is your
secondary insurance), benefits we have paid
to the provider, and benefits we have paid to
the beneficiary. A check number will appear
here only if a check accompanies your EOB.
15. Beneficiary Liability Summary—You may
be responsible for a portion of the fee your
doctor has charged. If so, you’ll see that
amount itemized here. It will include any
charges that we have applied to your annual
deductible and any cost-share or copayment
you must pay.
16. Benefit Period Summary—This section
shows how much of the individual and
family annual deductible and maximum
out-of-pocket expense you have met to date.
We calculate your annual deductible and
maximum out-of-pocket expense by fiscal
year. See the Fiscal Year beginning date in
this section for the first date of the fiscal
year.
17. Remarks—Explanations of the codes or
numbers listed in the “See Remarks” section
will appear here.
18. Toll-Free Telephone Number—Questions
about your TRICARE explanation of
benefits? Please call PGBA at this toll-free
number. Our professional customer service
representatives will gladly assist you.
APPENDIX
SECTION 8
West Region Explanation of Benefits Statement Sample Figure 8.3

44
How to Read Your TRICARE EOB for
the West Region
1. Mail-to Name and Address—We mail the
TRICARE EOB directly to the patient (or
patient’s parent or guardian) at the address
given on the claim. (Note: Be sure your
doctor has updated your records with your
current address.)
2. Date of Notice—The date we prepared your
TRICARE EOB.
3. Sponsor SSN/Sponsor Name—We process
your claim using the Social Security number
of the military service member (active duty,
secondary insurance), benefits we have paid
to the provider, benefits we have paid to the
beneficiary.
14. Beneficiary Share—You may be responsible
for a portion of the fee your doctor has
charged. If so, you’ll see that amount
itemized here. It will include any charges
that we have applied to your annual
deductible and any cost-share or copayment
you must pay.
15. Out of Pocket Expense—This section
shows how much of the individual and
family annual deductible and maximum

INDEX
SECTION 10
out-of-pocket expense you have met to date.
retired, or deceased) who is your TRICARE
We calculate your annual deductible and
sponsor.
maximum out-of-pocket expense by fiscal
4. Patient Name—The patient who received year. See the Fiscal Year Beginning date in
medical care and for whom this claim was this section for the first date of the fiscal
filed. year.
5. Claim Number—We assign each claim a 16. Remark Codes—Explanations of the codes
unique number. This helps us keep track of or numbers listed in Remarks (12) will
the claim as it is processed. It also helps us appear here.
find the claim quickly whenever you call or
17. Paid To—The name of the provider or
write us with questions or concerns.
facility to whom the claim was paid.
6. Check Number—A Check Number will
18. Regional Contractor— The name “TriWest
appear here only if a check accompanies
Healthcare Alliance Corp.” and the TriWest
your EOB.
logo will appear here.
7. Toll-Free Number/Web Address—How you
can reach us (TriWest) if you have questions.
8. Service Provided By—Who provided your
medical care, the number and type of
services, and the procedure codes.
9. Date of Services—The date you received the
care.
10. Amount Billed—The fee charged by your
doctor, hospital, or lab for the medical
services you received.
11. TRICARE Allowed—This is the amount
TRICARE approves for the services you
received.
12. Remarks—If you see a code or a number
APPENDIX
SECTION 8

in this section, look at the Remark Codes in

section (16) for more information about
your claim.
13. Claim Summary—Here we give you a
detailed explanation of the action we took
on your claim. You will find the following
totals: amount billed, amount approved by
TRICARE, non-covered amount, amount
(if any) that you have already paid to the
provider, amount your primary health
insurance paid (if TRICARE is your

45
List of Figures
Figure 1.1 TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Figure 1.2 TRS Wallet Card (front) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Figure 1.3 TRS Wallet Card (back) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Figure 2.1 Outpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Figure 2.2 Inpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Figure 2.3 Clinical Preventive Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Figure 2.4 Behavioral Health Care Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . .12
Figure 2.5 Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . .17
Figure 3.1 Regional Claims Processing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Figure 3.2 Overseas Claims Addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Figure 5.1 TRICARE Appeal Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Figure 5.2 Regional Appeals Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Figure 5.3 Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Figure 5.4 Reporting Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Figure 8.1 North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . .40
Figure 8.2 South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . .42
Figure 8.3 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . .44

46
 LIST OF FIGURES
SECTION 9
Index
A C
Abortion, 17 Camps, 18
Abuse, 10, 14, 34 Cancer, 10, 18, 20
Accident, 9-10, 24 Cancer screening, 10, 20
Acupuncture, 18 Cardiovascular disease, 10
Acute inpatient psychiatric care, 12 Cardiac rehabilitation, 17
Adjunctive dental care, 17 Catastrophic cap, 1, 36
Adjunctive dental services, 8 Certificate of creditable coverage, 28
Admission(s), 7-8, 10, 12-13, 19, 38 Certificate of Recognition, 17
Adoption, 26-27 Chair lifts, 19

INDEX
SECTION 10
Allergy test, 9 Child, 10-12, 19, 26-27, 32, 36-37
Ambicabs, 9 Children, 11, 13, 16, 26
Ambulance, 9, 20 Chiropractic care, 17
American Diabetes Association, 17 Claim, 6, 8, 15, 17, 19, 21-24, 26-27, 30-32,
Ancillary services, 9 37-38, 41, 43, 45
Anesthesia, 10, 18 Clinic, 7, 37
Annual deductibles, 1 Clinical preventive services, 10-11, 19-20
Appeal, 24, 31-32 Colorectal cancer, 10
Arch supports, 18 Contact lenses, 17
Artificial insemination, 18 Contingency operation, 36
Assistance coordinator, 30, 35 Continued Health Care Benefit Program
Attending physician, 17 (CHCBP), 16, 28, 36
Authorized provider, 1, 6-8, 11, 18-19, 21, 23, Copayment, 14-15, 21, 23-24, 41, 43, 45
31-32, 37-38 Cost-share, 1, 6, 21, 23-24, 36-37, 41, 43, 45

INDEX
SECTION 10
Autopsy services, 18 Counseling, 10, 18-19
Coverage, 1, 7, 9-17, 19, 22-24, 26-30, 36, 38
B Covered services, 8-13, 15-21, 36-37
Behavioral health care, 8, 11-14, 17, 31, 33 Cranial orthotic device, 17
Beneficiary, 9, 13, 19, 21, 23-24, 27-28, 30-33, Custodial care, 19
36, 41, 43, 45 Custodial parent, 31
Beneficiary counseling and assistance
coordinators (BCAC), 30, 36 D
Billed, 24, 34, 36, 41, 43, 45 Death of a spouse, 26
Birth, 11, 17-19, 26-27, 30, 32-33 Defense Enrollment Eligibility Reporting System
Birth control, 18 (DEERS), 7, 26, 29-30, 36
Birth defect, 17 Defense Manpower Data Center Support Office
Blood products, 10 (DSO), 28, 30
Blood pressure screening, 10 Denial, 23, 31-32, 37
Bone marrow transplants, 18 Dental care, 17-18
Brace, 18 Dental services, 16
Brand name, 15 Detoxification, 12, 14
Breast cancer, 10 Diabetes, 17-19
Breastfeeding, 19 Diagnosis-related group (DRG), 14, 18
Breast pumps, 17 Diagnostic tests, 19-20
Disabilities, 12, 18
Disability, 19, 37

47
Disease, 10, 18-19, 23 Hospitals, 6, 9, 18-19, 38, 41, 43,
Disorder, 8, 12-14, 18 Human immunodeficiency virus (HIV), 10
Divorce, 26-27 Human papillomavirus (HPV), 11
Drug abuse, 14
Durable medical equipment (DME), 7, 9 I
Dyslexia, 19 Immunizations, 10-11, 19
Incapacitation, 37
E Indian Health Service, 23, 37
Extended Care Health Option (ECHO), 1, 8 Infant, 17, 19
Education, 17 Infantile glaucoma, 17
Electrocardiograms, 10 Infectious disease, 10
Eligibility, 27-31, 36 Influenza vaccine, 10
Emergency care, 7 Inpatient admissions, 8, 12
End-stage renal disease, 18 Inpatient behavioral health care, 31
Enrollment, 2, 7, 11, 16, 30, 36 Inpatient psychotherapy, 13
Examinations, 10, 18-19 Inpatient services, 10
Exclusions, 8-13, 15-21 In-vitro fertilization, 18
Explanation of benefits (EOB), 24-25, 31, 34,
37, 39, 41, 43, 45 K
Eyeglasses, 17 Keratoconus, 17

F L
Family member, 1, 7, 18-19, 26-30, 36, 38 Laboratory, 9-10, 20
Family therapy, 13-14 Laboratory services, 9, 20
Federal Employees Health Benefits program, LASIK, 18
1, 27 Learning disability, 19
Fiscal year, 11-14, 36, 41, 43, 45 Licensed professional counselors, 11
Food, 1, 18 Limitations, 8-19
Food substitutes, 18 Line-of-duty care, 23
Fraud and abuse, 34 Loss of eligibility, 27-28

G M
Gamete intrafallopian transfer, 18 Mammograms, 10
Gastric bypass, 18 Marriage, 11, 26, 30
Gastroplasty procedures, 18 Maternity, 7, 9, 16
General nursing, 10 Maternity services, 16
Generic drug use policy, 15 Maternity ultrasounds, 16
Generic equivalent(s), 15-16 Meals, 10
Generic medications, 15 Medicabs, 9
Genetic testing, 10, 18 Medical facility, 37
Grievance, 32-33 Medical insurance, 19
Group sessions, 13 Medical necessity, 13, 15-16, 31, 38
Medicare, 10, 19, 30
H Medications, 1, 10, 12, 14-16, 19
Hepatitis B screening, 10 Medication management, 12
Home health services, 8-9 Military treatment facility (MTF), 1, 7, 14, 21,
Hospice care, 8 23, 30, 37
Hospitalization, 10, 12 Molding helmet, 17

48
 INDEX
SECTION 10
N Play therapy, 13
Postpartum, 16-17, 19
National Guard and Reserve, 1, 23, 30
Postpartum care, 16
Naturopaths, 19
Pregnancy, 10, 16-18
Necessary mastectomy, 17
Premiums, 26, 28-29
Network pharmacies, 1, 15
Prenatal care, 16
Network provider, 6, 8, 11, 21, 31, 37, 38
Prescribing provider/physician, 15, 22
Newborn, 16, 19, 26
Prescription, 1, 12, 14-15, 18, 22, 24
Non-adjunctive dental treatment, 18
Preventive care, 19
Non-appealable issue(s), 31-32
Preventive therapy, 10
Nonavailability statements (NAS), 31
Prior authorization, 6-8, 11-15, 31-32, 38
Non-covered behavioral health care services, 11
Prostate cancer, 10
Nonemergency, 8, 12
Prosthetic devices, 9

INDEX
SECTION 10
Non-formulary drugs, 15-16
Provider(s), 1, 3, 6-9, 11-12, 15-19, 21-24,
Non-network pharmacy, 15, 22
31-34, 36-38, 41, 43, 45
Non-network provider, 6, 8, 21, 23, 37
Psychiatric treatment, 19
Nonparticipating provider, 6, 21, 24, 36-37
Psychiatrist, 13
Nonsynostic positional plagiocephaly, 17
Psychoanalysis, 13
Nutrition, 10, 18
Psychogenic, 19
O Psychological disorders, 13
Psychological testing, 12
Obesity, 18-19 Psychologist, 13
Occupational therapy, 9 Psychotherapy, 12-13, 19
Orthomolecular psychiatric therapy, 19 Pulmonary rehabilitation, 17
Orthopedic shoes, 18 Purchase lockout, 27-28
Osteopathic manipulation, 9
Other health insurance (OHI), 15, 22-24, 36-37 Q
Outpatient, 8-11, 13-14, 17, 19, 36
Quantity limits, 15
Outpatient behavioral health, 8
Outpatient care, 14, 36
R
Outpatient diabetic self-management, 17
Outpatient psychotherapy, 13 Radiology services, 10
Outpatient services, 9 Radiology, 6, 9-10, 38
Reconsideration, 31-32
P Reconstructive surgery, 17
Records, 22-24, 30, 41, 43, 45
Pap smears, 10, 11, 20
Referral, 6, 8, 11
Parenteral, 18
Refractive corneal surgery, 19
Partial day treatment, 12
Regional contractor, 2, 6-9, 11-14, 17, 21-23,
Partial hospitalization, 12
26-27, 30-34, 37-38, 41, 43, 45
Partial reimbursement, 15, 24
Rehabilitation, 9, 12-14, 17
Participating provider, 6, 21, 24, 31, 36-37
Reimbursement, 6, 8, 14-15, 17, 22-24
Pastoral counselor, 11
Remote locations, 23
Pathological services, 20
Reserve Affairs Web site, 1, 30
Patient information, 22
Residential treatment center (RTC), 13
Personal physician, 9
Retail pharmacies, 15
Pharmacy, 1, 14-16, 22, 24, 34
Rh immune globulin, 10
Phase III cardiac rehabilitation, 17
Routine osteoporosis screening, 9
Physical examination, 19
Routine preventive procedure, 11
Physical therapy, 9-10
Rubella, 10
Physician, 9, 11, 15-17, 19-20, 22, 31
Rubella antibodies, 10
Plastic surgery, 17
Runaway child, 19
49
S Treatment, 1, 7, 9, 12-14, 17-21, 23-24, 30-31,
36-37
Safe sexual practices, 10
TRICARE-allowable charge, 6, 21, 24, 31,
School physicals, 11
36-38, 43
Selected Reserve, 1, 27
TRICARE-authorized provider, 1, 6, 8, 11, 21,
Serious birth defect, 17
23, 37-38
Serious injury, 17
TRICARE Area Office (TAO), 3, 8, 23, 30
Serious medical condition, 7, 9
TRICARE Dental Program, 16, 23
Sexual dysfunction, 19
TRICARE Europe, 2-3, 23
Sexual inadequacy treatment, 19
TRICARE Extra, 1
Shoe inserts, 18
TRICARE Global Remote Overseas (TGRO), 1
Skilled nursing facility, 9-10
TRICARE formulary search tool, 16
Skin, 11
TRICARE Latin America and Canada (TLAC),
Smoking, 19
2, 3, 23, 37
Social Security number (SSN), 21, 28, 32-33,
TRICARE Mail Order Pharmacy, 1, 14-15
41, 43, 45
TRICARE Management Activity (TMA), 23, 28,
Spas, 19
34, 37
Specialist, 9, 11, 33
TRICARE Overseas Program (TOP), 23
Special care units, 10
TRICARE Pacific, 2-3, 23
Special diets, 10
TRICARE Point of Contact, 3, 22-23
Speech, 9-10
TRICARE Prime, 1
Speech pathology services, 9
TRICARE Prime Remote (TPR), 1
Speech therapy, 10
TRICARE regional contractor, 2, 26
Spouse, 1, 26, 36
TRICARE regions, 8, 38
Sponsor, 19, 21, 26-28, 30, 32-33, 36, 41, 43, 45
TRICARE Reserve Select (TRS), 1-2, 6-7, 9,
Stabilization, 14
16-17, 22-23, 26-30, 36, 38
Stem cell, 8
TRICARE Reserve Select wallet card, 7
Sterilization reversal surgery, 19
TRICARE retail network pharmacy, 1, 15
Stress, 10, 18
TRICARE Retail Pharmacy, 24
Stress management, 18
TRICARE Service Center (TSC), 2-3, 8, 21,
Substance abuse, 10
26, 30
Substance use disorder, 12, 14
TRS Request form, 7, 26-27, 29
Suicide risk assessment, 10
Tuberculosis, 10
Supplements, 18, 23, 37
Surgical care, 9
U
Survivor, 29
Survivor coverage, 29 Ultrasounds, 9, 16
Swimming pools, 19 Unauthorized benefit, 34
Unauthorized provider, 18, 31
T Uniformed services, 30, 36-38
Uniformed services identification (ID) card, 30
Taxi service, 9
United Concordia Companies, Inc., 16
Tests, 9-10, 12, 19-20
US Family Health Plan (USFHP), 1
Tetanus, 10
Third-party liability, 24
V
Tobacco, 10
Transfers, 9 Vaccines, 10
Transitional Assistance Management Program Vision screening, 10
(TAMP), 27, 38 Vitamins, 18
Transitional medical coverage, 28 Vocational counseling, 18
Transplants, 8, 18
Traveling, 8, 21

50
W
Waiver, 14
Weight loss, 18-19
Whirlpools, 19
Wisconsin Physicians Service (WPS), 22

X
X-rays, 10, 17

INDEX
SECTION 10

51
Notes

52
 TRICARE Reserve Select TRICARE Reserve Select
Europe Overseas Providers North Region Network Providers

O V E R S E A S

N E T W O R K
Collect CostShare: 20% of TRICAREallowable charge Collect CostShare: 15% of negotiated rate
By law, bill no more than 15% above allowable charge. Submit Claims To: Health Net Federal Services, LLC
Visit www.tricare.mil/cmac/ for allowable amount. c/o PGBA, LLC/TRICARE
Submit Claims To: WPS—TRICARE Overseas Claims P.O. Box 870140
P.O. Box 8976 Surfside Beach, SC 295879740
Madison, WI 537088976 Questions? 18005552605
Questions? 16083012310 www.healthnetfederalservices.com
www.TRICARE4u.com www.myTRICARE.com

TRICARE Reserve Select TRICARE Reserve Select

Latin America and Canada South Region Network Providers
Overseas Providers

O V E R S E A S

N E T W O R K
Collect CostShare: 20% of TRICAREallowable charge Collect CostShare: 15% of negotiated rate
By law, bill no more than 15% above allowable charge.
Visit www.tricare.mil/cmac/ for allowable amount. Submit Claims To: TRICARE South Region
Claims Department
Submit Claims To: WPS—Overseas Claims P.O. Box 7031
P.O. Box 7985 Camden, SC 290207031
Madison, WI 537077985
Questions? 18772983408
Questions? 16083012310 www.humanamilitary.com
www.TRICARE4u.com www.myTRICARE.com

TRICARE Reserve Select TRICARE Reserve Select

Pacific Overseas Providers West Region Network Providers
O V E R S E A S

N E T W O R K
Collect CostShare: 20% of TRICAREallowable charge
Collect CostShare: 15% of negotiated rate
By law, bill no more than 15% above allowable charge.
Visit www.tricare.mil/cmac/ for allowable amount. Submit Claims To: West Region Claims
WPS
Submit Claims To: WPS—Overseas Claims
P.O. Box 77028
P.O. Box 7985
Madison, WI 537071028
Madison, WI 537077985
Questions? 1888TRIWEST
Questions? 16083012310
www.triwest.com
www.TRICARE4u.com
 N O N - N E T W O R K TRICARE Reserve Select Using These Cards
North Region Non-Network Providers
Collect CostShare: 20% of TRICAREallowable charge These quickfact cards are designed to
By law, bill no more than 15% above allowable charge. give providers ataglance information
Visit www.tricare.mil/cmac/ for allowable amount.
about your TRICARE costshares,
Submit Claims To: Health Net Federal Services, LLC claims, and regional contractors. Punch
c/o PGBA, LLC/TRICARE out the perforated card for the region in
P.O. Box 870140
Surfside Beach, SC 295879740
which you reside—overseas regions are
Questions? 18005552605 on the left, stateside regions are on the
www.healthnetfederalservices.com right—carry it with you at all times,
If you have never treated a TRICARE beneficiary, contact Health Net to
become a certified provider to ensure claims are processed smoothly.
and present it, along with your
TRICARE Reserve Select (TRS)
wallet card, when you receive care.

The cards on this page are not meant to

TRICARE Reserve Select replace your TRS wallet card, which
N O N - N E T W O R K

South Region Non-Network Providers

serves as proof of TRICARE coverage.
Collect CostShare: 20% of TRICAREallowable charge
By law, bill no more than 15% above allowable charge.
Presenting both cards at the time of
Visit www.tricare.mil/cmac/ for allowable amount. care will help ensure that your provider
processes your claims correctly.
Submit Claims To: TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC 290207031
Questions? 18772983408
www.humanamilitary.com
If you have never treated a TRICARE beneficiary, contact Humana Military
to become a certified provider to ensure claims are processed smoothly.

TRICARE Reserve Select

N O N - N E T W O R K

West Region Non-Network Providers

Collect CostShare: 20% of TRICAREallowable charge
By law, bill no more than 15% above allowable charge.
Visit www.tricare.mil/cmac/ for allowable amount.

Submit Claims To: West Region Claims

WPS
P.O. Box 77028
Madison, WI 537071028
Questions? 1888TRIWEST
www.triwest.com
If you have never treated a TRICARE beneficiary, contact TriWest to become
a certified provider to ensure claims are processed smoothly.
Patient Bill of Rights and Responsibilities
As a patient in the military health system,
you have the right to:
• Receive accurate, easy-to-understand information to
help you make informed decisions about TRICARE
programs, medical professionals, and facilities.
• Have a choice of health care providers that is sufficient
to ensure access to appropriate high-quality health care.
• Access emergency health care services when and
where the need arises.
• Receive and review information about diagnosis,
treatment, and the progress of your condition, and
to fully participate in all decisions related to your
health care, or to be represented by family members,
conservators, or other duly appointed representatives.
• Receive considerate, respectful care from all members
of the health care system without discrimination
based on race, ethnicity, national origin, religion, sex,
age, mental or physical disability, sexual orientation,
genetic information, or source of payment.
• Communicate with health care providers in confidence
and to have the confidentiality of your health care
information protected.You also have the right to review,
copy, and request amendments to your medical records.
• Have a fair and efficient process for resolving differences
with your health plan, health care providers, and the
institutions that serve them.
For more information about your rights, visit
www.tricare.mil/Patientrights/default.cfm.
Printed: October 2007
As a patient in the military health system,
you have the responsibility to:
• Maximize healthy habits, such as exercising, not
smoking, and maintaining a healthy diet.
• Be involved in health care decisions, which means
working with providers in developing and carrying
out agreed-upon treatment plans, disclosing relevant
information, and clearly communicating your wants
and needs.
• Be knowledgeable about TRICARE coverage
and program options.
You also have the responsibility to:
• Show respect for other patients and health
care workers.
• Make a good-faith effort to meet financial obligations.
• Use the disputed claims process when there is
a disagreement.
• Report wrongdoing and fraud to appropriate
resources or legal authorities.
Please provide feedback on this handbook at
http://www.tricare.mil/evaluations/feedback.
www.tricare.mil/reserve/reserveselect

Health Net Federal Services, LLC

1-800-555-2605

Humana Military Healthcare Services, Inc.

1-800-444-5445

TriWest Healthcare Alliance, Corp.

1-888-TRIWEST (1-888-874-9378)

TRICARE Overseas (TRICARE Europe,TRICARE

Latin America and Canada, and TRICARE Pacific)
1-888-777-8343

TRICARE Mail Order Pharmacy

1-866-DoD-TMOP (1-866-363-8667)

TRICARE Retail Network Pharmacy

1-866-DoD-TRRX (1-866-363-8779)

HA661BET10074