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How TRICARE Calculates Payment with Other Health Insurance

TRICARE requires coordination of benefits with other health insurance (OHI) coverage. TRICARE does not always pay the beneficiary’s OHI copayment or the balance left over after the OHI payment. However, the beneficiary usually owes very little to nothing. The TRICARE payment calculation is based on the provider's status. Note: Most inpatient facilities have other calculations not listed below.

TRICARE network providers/non-network who accept TRICARE assignment (participating)
TRICARE pays the lower of:

  • the billed amount minus the OHI payment
  • the amount TRICARE would have paid without OHI
  • the amount the beneficiary owes after the OHI paid (usually the OHI copayment or cost-share)

Non-network providers who do not accept TRICARE assignment (nonparticipating)
Nonparticipating providers may only bill the beneficiary up to 115 percent of the TRICARE allowed amount. If the OHI paid more than 115 percent of the allowed amount, no TRICARE payment is authorized, as the charge is considered paid in full and the provider may not bill the beneficiary. Otherwise, TRICARE pays the lower of:

  • 115 percent of the allowed amount minus the OHI payment
  • the amount TRICARE would have paid without OHI
  • the amount the beneficiary owes after the OHI paid (usually the OHI copayment or cost share)

Staff model HMOs, group HMOs and other capitated OHI plan providers
When a beneficiary is enrolled in one of these OHI plans, the provider/group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans, the beneficiary generally only receives a copayment receipt – an itemized bill or Explanation of Benefits (EOB) is not available.

In these cases, the beneficiary submits a Beneficiary Claim Form DD2642 with a copy of the receipt and the copayment is considered the billed amount. Deductibles and cost shares are applied and the beneficiary may not receive full reimbursement of their HMO copayment.

Find out more information regarding how TRICARE works with OHI.