Claims
If the date of service is before Jan. 1, 2025, AND the claim was submitted to HNFS by April 30, 2025:
In order to view status information, the National Provider Identifier (NPI) on your www.tricare-west.com account must match the billing NPI on the claim.
Starting May 1, 2025, check with TriWest on all other claims.
There are specific guidelines regarding TRICARE and other health insurance. Visit the How TRICARE Works with Other Health Insurance page.
You should receive a remittance adivce which will explain why a claim was denied. You can view your remittance advice online (log in required).
Before delivering care, network providers must notify TRICARE patients if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services. If the beneficiary does not sign a Request for Non-Covered Services form or equivalent, you are financially responsible for the cost of non-covered services you deliver.
Hold Harmless Policy for Network Providers
A network provider may not bill a TRICARE beneficiary for services not covered, except in the following circumstances:
- If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary.
- If the beneficiary was informed that services were not covered and agreed in advance and in writing to pay for the services.
Hold Harmless Policy for Non-Network Providers
Non-network providers should also inform beneficiaries in advance if services are not covered. Although not required, non-network providers are strongly encouraged to document payment agreements.
Claims can be recouped for various reasons, including, but not limited to:
- Loss of eligibility
- Claim processed without other health insurance information
- Erroneous payment of a non-covered service
- Review of the medical records does not show medical need for the service
The recoupment reason is listed on the recoupment letter or on an attached list of claims. If the recoupment is because the service is not covered under TRICARE or not medically necessary, then appeal rights are given in the recoupment letter.
You may visit the Defense Health Agency's website for current TRICARE allowable charges, also referred to as CHAMPUS Maximum Allowable Charges (CMAC).
Non-participating TRICARE non-network providers can bill up to 115 percent of the CMAC.
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