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Tricare Medicare Claims Processing Requirements

Individuals who have dual eligibility with Tricare and Medicare insurance benefits will have their insurance claims processed by both of the health insurance companies to pay insurance claims. Tricare is a health care program of the U.S. Department of Defense Military Health System. The process of filing claims for both Tricare and Medicare is handled by a contractor of Tricare Dual-Eligibility Fiscal Intermediary Contract, or TDEFIC. The dual eligibility beneficiaries become entitled to a special program called Tricare for Life if they meet certain requirements. Beneficiaries with dual eligibility, whose claims will be processed by TDEFIC, fall into five categories, according to the Tricare Operations Manual, as of Feb. 1, 2008:



1) Tricare beneficiaries, who have earned Medicare Part A eligibility, have reached age 65 and enrolled in Medicare Part B.



2) Tricare beneficiaries who didn't earn Medicare Part A but purchased Medicare Part B.



3) Family members of active duty service members who are eligible for Medicare and have reached age 65.



4) Other Tricare-eligible individuals with Medicare eligibility due to disability or other conditions determined by Medicare and who also have enrolled in Medicare Part B.



5) Family members of active duty service members with Medicare eligibility due to disability or other conditions determined by Medicare.

  1. Claims Process

    • On claims where Tricare and Medicare share insurance costs, Medicare pays first and Tricare pays second. If another insurance company is involved, Medicare still pays first, the other provider would pay second and then Tricare would pay what it is required to pay. The Wisconsin Physicians Services, or WPS, handles all Tricare claims processing in the Tricare West Region and Tricare for Life. International SOS Assistance Inc. has partnered with WPS to handle the overseas program as of Sept. 1, 2010. PGBA LLC processes all claims in the North and South regions.

    Tricare For Life

    • Tricare for Life benefits coverage applies to individuals who are entitled to Medicare Part A and purchase Medicare Part B benefits, except active duty family members. Entitlement to the plan consists of age or disability, including end-stage renal disease. Uniformed services retirees, which includes retired Reserve members, Medicare-eligible widows and widowers and Medicare-eligible family members can receive Tricare for Life. Dependent parents and parent-in-laws can only enroll in Tricare Senior Pharmacy Benefits and receive military treatment facility services on a space-available basis. Medicare pays first on civilian claims processing and then Tricare for Life pays the Tricare-covered services directly to the provider. Enrollees receive a Medicare summary notice and a Tricare for Life explanation of benefits that details what benefits were paid to the civilian provider.

    Restrictions

    • If care is given outside the United States and not within a U.S. Territory, such as American Samoa, Guam, the Northern Mariana Islands and the U.S. Virgin Islands, Tricare will go by its standard cost-sharing guidelines because it is the primary provider. Medicare does not give overseas care. All claims go to WPS or PGBA for processing, except for overseas claims that should be forwarded to the International SOS Assistance.

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