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TRICARE East Beneciary FAQs: Claims and Appeal Submissions
GENERAL CLAIMS
What is an Explanation of Benets (EOB), and how can I view mine?
A TRICARE EOB is an itemized statement that shows what
action TRICARE has taken on your claims. It is not a bill. ey
are available in beneciary self-service or the Humana Military
mobile app.
How long does it take to process a claim?
Claims processing may take up to 90 days from the date of receipt.
Where can I view the claim’s status?
Use beneciary self-service and the mobile app to view
claim status. See tutorials, beneciary self-service guide and
mobile app FAQ.
Why is there limited access to some claims?
Access is limited based on these situations:
• If the dependent is 18 or older
• If there is no completed Personal Health Information (PHI)
release consent between spouses on le
• Sensitive claims for dependents ages 12-18 will not be shown
How do I grant access for another person to be able to discuss
these claims by phone?
Complete and return the TRICARE East Region authorization
for general information form or the TRICARE East region
authorization for release of sensitive information form.
Return completed form to Humana Military:
Humana Military Privacy Oce
PO Box 740062
Louisville, Kentucky 40201-7462
Fax: (877) 298-3407
Humana Military will follow all federal and state laws and
regulations that are more stringent.
Why would the TRICARE claims reimbursement amount differ from
the total bill charges?
All TRICARE claims are subject to TRICARE Maximum
Allowable Charge (TMAC). TMAC is the maximum amount
TRICARE will pay a doctor or other provider for a procedure,
service or equipment. is is connected to Medicare’s allowable
charges by law.
When can a provider bill for services above TMAC?
Non-participating providers can charge you up to 15% more
than TMAC, known as balance billing. Make sure to review
your TRICARE EOB to verify allowed amounts. Learn more
about costs.
How is Other Health Insurance (OHI) information updated?
1. Complete the OHI questionnaire.
2. Fax: (608) 221-7536 (Preferred method)
or mail to:
TRICARE East Region
PO Box 8923
Madison, WI 53708-8923
Note: Failure to update OHI details with your provider(s) or
contractor may result in TRICARE denying claims.
Why is a Third Party Liability (TPL) form (DD2527) requested/required?
e Federal Medical Recovery Act allows TRICARE to be
reimbursed for its costs of treating you if you are injured in an
accident that was caused by someone else.
• Humana Military will send you the statement of personal
injury-possible third party liability form (DD Form 2527)
if a claim is received that appears to have TPL.
• You must complete and sign this form within 35 calendar
days. e claim cannot be processed until the form is
returned to Humana Military.
Return completed form to:
TRICARE East Region
Attn: ird Party Liability (TPL)
PO Box 8968
Madison, WI 53707-8968
Fax: (608) 221-7539
How do you determine if I utilized my Point of Service (POS) option?
If you have TRICARE Prime, you are using POS when:
• Receives care from a network or non-network TRICARE-
authorized provider without a referral from their Primary
Care Manager (PCM).
• Receives care for clinical preventive services from a non-
network provider.
• Self-refers to a civilian specialty care provider aer a referral
has been authorized to a military hospital or clinic specialty
care provider.
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TRICARE East Beneciary FAQs: Claims and Appeal Submissions
• Self-refers to a non-network specialty care provider
aer a referral has been authorized to a network specialty
care provider.
What are non-covered services?
• Exclusions
• TRICARE Q&A: Non-Covered Services from Network and
Participating Non-Network Providers (East Region)
What are fraud and abuse?
Fraud is when a person or organization deliberately deceives
others to gain some sort of unauthorized benet.
Abuse is when providers supply services or products that are
medically unnecessary or that do not meet professional standards.
• Learn how to report fraud or abuse.
SELF-FILING CLAIMS
How do I submit a claim for services or supplies provided by
medical care personnel?
To process a beneciary-submitted claim (Claim form), you
must include the following required information. Missing
information will delay the processing of the claim:
• Beneciary’s rst and last name (include on all attachments)
• Beneciary’s address
• Relationship to the sponsor
• Beneciary’s date of birth
• Beneciary’s sex
• Sponsor’s name and ID (included on all attachments)
• Other Health Insurance (OHI) EOB
• Beneciary or authorized person’s signature
• Itemized bills with the provider information. is includes
the providers name, address and NPI number if available.
• A description of the condition or diagnosis codes. If this
information is not on the billing statement, the information
can be obtained from the provider.
• Procedures performed or CPT codes. If this is not on the
billing statement, the information can be obtained from
the provider.
• Proof of payment if you have already made a payment to
the provider
• Signature of beneciary or authorized party (Box 12a)
is required for the claim to be processed. Please date all
signatures on documentation to make sure that we can
process claims in a timely manner.
Check out this step-by step guide on completing the claim form.
To submit the claim form and supporting documentation:
TRICARE East Region: New Claims
PO Box 7981
Madison, WI 53707- 7981
Fax: (608) 327-8522
How do I submit a claim for a physical, occupational or speech therapy?
Follow the steps listed above. Please date all signatures on
documentation to make sure that we can process claims in a
timely manner. ese claims require the following additional
documents for the claim to process:
• A valid physician’s order and signed treatment plan
covering the dates of service submitted on the claim
must be on le. Frequency of submission depends on the
length of treatment included on the physician’s order. is
information can be obtained from the provider performing
the services. If this information is not on le, the claim must
be returned to the provider for the missing information
which will create a delay in the processing of the claim.
• erapy progress notes are required every three months.
is information can be obtained from the provider
performing the services. If this information is not on le,
the claim must be returned to the provider for the missing
information which will create a delay in the processing of
the claim.
• For beneciaries ages 3-21, a current Individualized
Education Program (IEP) Public Facility Use Certication
Form (PFCF) or documentation from the public school
system that the beneciary (ages 3 to 21) is not enrolled
in a public school and is not receiving speech services is
required. We can also accept a signed written statement
from the parents stating that the beneciary is in a private
or home school and is not receiving any special education
from a public agency. If this information is not on le, the
claim must be returned to the provider for the missing
information which will create a delay in the processing of
the claim.
• e beneciary’s rst and last name and the sponsor’s name
and ID should be included on all pages of the documents to
ensure the documents are correctly attached to the claim.
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TRICARE East Beneciary FAQs: Claims and Appeal Submissions
How long do I have to le a claim?
All claims must be led within one year aer the service
took place.
How long do I have to resubmit a claim that was returned to me?
If a claim submission is returned for additional information,
the re-submission of the claim must be received within the
ling deadline or within 90 days of notice.
Where can I get more information on specic claim types?
• Banked Donor Milk (BDM) claims
• Breastfeeding supplies
• Durable Medical Equipment (DME)
• TRICARE East Region Authorization of Release for
General Information
• TRICARE East Region Authorization for Release of
Sensitive Information
APPEAL SUBMISSION PROCESS
Do I have the right to appeal a denied claim?
Yes. If you do not agree with a decision made about your
benet. Please see directions for appeals on your EOB.
How long do I have to submit a TRICARE claims appeal?
Claim appeal submission receipt is no later than 90 calendar
days aer the date of the initial denial determination letter
or EOB.
Where do I submit a claim appeal?
Email: [email protected] (preferred method)
Fax: (877) 850-1046
Humana Military appeals
PO Box 740044
Louisville, KY 40201-7444
