FAQs

What is ambulatory surgery?

A: Ambulatory surgery is surgery that does not require you to stay overnight in a hospital. You may hear it called outpatient surgery or same-day surgery. If you must stay overnight, that is inpatient surgery.

Does TRICARE For Life cover ambulatory surgery?

[Ambulatory Surgery](http://www.tricare.mil/CoveredServices/IsItCovered/AmbulatorySurgery.aspx?sc_database=web target="_blank" rel="noopener noreferrer")

Can I use a "corrected claim" as an appeal?

A: Yes. A beneficiary or provider may submit a "corrected claim" that changes the diagnosis and/or procedure code. When that happens, the claim becomes a formal appeal.

How do I appeal a denial?

A: In many cases your provider of services will file the appeal. However, beneficiaries also have the right to file an appeal as well. If you disagree with the determination on your claim, you have the right to request reconsideration. Your SIGNED, written request must state the specific matter with which you disagree and MUST be mailed to the following address no later than ninety (90) days from the date of the denial. Upon receiving your request, all TRICARE For Life claims for the entire course of treatment will be reviewed. Along with the written request, please include any additional documentation that was not included with the original submission.

WPS TRICARE For Life ATTN: APPEALS P.O. BOX 7490 Madison, WI 53707-7490

Appeals can also be sent by your provider to TFL through the secure portion of the TRICARE4u.com website.

What kind of denied charges are appealable?

A: These denials include, but are not limited to, the lack of establishing medical necessity, services not deemed non-covered under policy, insufficient diagnosis, and medical limits being exceeded. The Explanation of Benefits (EOB) that you receive will provide appeal rights and information on how to file an appeal. The following denial codes are appealable: 01D, 005, 006, 008, 009, 010, 012, 013, 014, 015, 016, 019, 023, 025, 026, 027, 031, 032, 035, 037, 041, 050, 052, 053, 057, 059, 061, 062, 066, 067, 153, and 277.

How do I file a medical appeal?

To file a medical appeal, follow the instructions on your explanation of benefits (EOB) or determination.

For more information on the appeals process, visit File a Complaint

Do I need an authorization?

When TFL is the primary payer for certain services, you will need preauthorization. When Medicare or other insurance is the primary payer, you will not.

TFL does not make referrals to specialists or other providers. TFL can help you with getting approvals.

Your provider will handle preauthorization in most cases. Contact your provider if you need to check on a request.

You will need preauthorization for these services when TFL is the primary payer:

• Skilled Nursing Facilities (SNF)
• Transplants
• Hospice when beneficiary only has Medicare Part B
• Extended Health Care Option
• Inpatient Mental Health and Substance Use Disorder
• Laboratory Developed Tests
• Femoroacetabular Impingement (FAI)
• Cancer Clinical Trials (CCT), reviewed for approvals by the authorization staff
• IVIG (Intravenous Immunoglobulin) Drugs
• AAT (Alpha-1 Antitrypsin) Drugs
• Low-Protein Modified Foods (LPMF) for Inborn Errors of Metabolism (IEM)
• Adjunctive Dental
• Home Health PPS
• Dental Anesthesia and Institutional Benefits
• Electroconvulsive Therapy (ECT)
• Transcranial Magnetic Stimulation (TMS)
• Psychoanalysis
• Applied Behavioral Analysis (ABA) services, contact regional contractor for authorization.

TFL will not approve services after the fact. If five days have passed since the service, your provider must submit a claim. They must include all supporting documents and send the claim through the website or by fax (608-301-2114). TFL may reduce payment 10% when services are not approved in advance, however ABA services will not be considered without an authorization.

What is balance billing?

A: TRICARE For Life (TFL) limits the amount a provider can charge you. If you get a bill for the difference between billed charges and the allowable charge after TFL (and other health insurance) has paid all they will pay, that is balance billing.

Participating providers cannot balance bill. A nonparticipating provider may bill up to 115% of the allowable charge. That is the same percentage used by Medicare.

What should I do if I receive a balance bill on Medicare’s allowed amount?

A: Contact your Medicare claims processor if you get a bill for more than 115% of Medicare’s allowed amount. You can find out who your Medicare claims processor is at Medicare.gov.

What should I do if I receive a balance bill?

A: Medicare has a limited allowed amount for services. You may see a provider who does not participate in Medicare. If that provider charges you 115% of the allowed limit or more, you need to document what you paid or must pay.

You can send different types of documents as evidence, including:

• Bills from the nonparticipating provider
• A demand letter from the nonparticipating provider or collection agency
• A copy of your canceled check
• Receipts from the nonparticipating provider

Submit this information to:

WPS/TRICARE Program Integrity P.O. Box 7516 Madison, WI 53707

What is a beneficiary and who are my beneficiaries?

A: For the purposes of TRICARE For Life a beneficiary is anyone who is eligible on DEERS and receiving TRICARE benefits. A beneficiary can be the sponsor (the person who served in the military) and the sponsor’s family members (spouse and children) who are registered in DEERS. For more beneficiary information and to find out who in your family may be eligible please visit TRICARE Eligibility

How do I file a claim?

A: TRICARE For Life claims are usually submitted by the provider of the services performed, either electronically or by paper claim. However, beneficiaries can also submit claims for their medical services. They fill out the Patient's Request for Medical Payment (DD form 2642) and attach itemized bills.

Itemized bills must include the following: Name and address of the provider (usually located in the letterhead), Dates of Service, Procedure code or description of each service, Diagnosis code or description of diagnosis and Charges for each service.

Balance due statements or Explanations of Benefits (EOB) from Other Health Insurance (OHI) are not acceptable itemized bills, however the supporting Medicare and Other Health Insurance Explanation of Benefits (EOB) that corresponds to the charges filed are required. We need to know what all of your OHI plans paid in order to make our final determination.

What should I pay close attention to when filing my own claim?

A: Many times claims are delayed or denied because the claim form wasn't filled out correctly or all the information wasn't provided. Here are some tips to help you file your claims correctly:

• Keep DEERS updated- Incorrect information in DEERS could cause your TRICARE For Life claim to be denied. Update DEERS now!
• Use the right form- File medical claims on a Patient's Request for Medical Payment (DD Form 2642)
• Fill in all 12 blocks- Include the sponsor's Social Security Number or Department of Defense Benefits Number, your home address and phone number, as well as any other pertinent information needed. Please see Completing Claim Form site for step by step instructions.
• Use the right diagnosis code- Your provider should give you a diagnosis code for all services he or she provided. Include that code with the description in Box 8a.
• Sign the claim form- Claims submitted without a signature will be denied payment.
• Notify TRICARE For Life if there is a third party involved- If you were hurt in an accident and someone else may bear responsibility, you have to let TRICARE For Life know by submitting a Statement of Personal Injury-Possible Third Party Liability (DD Form 2527) along with your medical claim form.
• File claims with Other Health Insurance (OHI) first- TRICARE For Life pays second to most other health insurance (OHI) programs. When you receive payment from your OHI, you can then file a claim with TRICARE For Life. Include a copy of your explanation of benefits from your OHI with your claim.
• Make copies- Keep copies of everything you submit to TRICARE For Life.
• Use the right claims address- Send your claim forms to the correct address to avoid delays. The correct address is WPS/TRICARE For Life, P.O. Box 7890, Madison, WI 53707-7890.
• File claims on time- Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. You are encouraged to send your claim form to TRICARE For Life as soon as possible after you receive care.
• Submit each claim separately- Filing multiple claims together could cause confusion.

Where do I file a claim?

A: Claims can be filed online through this web site. To submit online you must have an active account. Once you have created an account you can submit a new claim in the Message Center. If you would like to file the claim by postal mail, send all claims to:

WPS/TRICARE For Life P.O. Box 7890 Madison, WI 53707-7890

For more information on filing a claim please visit Completing Claim Form

In what circumstances do I need to file a claim?

A: In most cases, your provider will file your medical claims for you and you'll receive an explanation of benefits detailing what was paid. Sometimes, you'll need to file your own claims:

• When traveling
• If you get care from a non-participating provider
• If you're using TRICARE For Life and you see a Medicare non-participating provider
• Your provider of service does not file to TRICARE For Life
• TRICARE For Life is your third payer and your provider will not file to more than two insurances on your behalf.

How do I view my claims on TRICARE4u.com?

A: If you have not registered on TRICARE4u.com, the first step is to create an account. Please create an account. If you have already created an account you can login to view your claims. Once logged in you will be directed to the Claims Activity page where you can view your claims.

I have specific questions and I can’t locate the information I’m looking for on your site. How do I contact a representative?

A: You have four options to contact Customer Service for additional assistance.

1. Live chat with a customer service representative 24/5, from 5 AM Monday through 10 PM Friday CST. You can open a chat from the bottom right of the screen on any page within TRICARE4u.com.

2. Send us an email This form is only for general questions. To ask a question about your claims or other personal information, login to our secure message service to ensure privacy.

3. Login and go to the Message Center and send us a secure message.

4. Give us a call at 1-866-773-0404. One of our experienced representatives will help!

Where can I get more COVID information?

Please see TRICARE's COVID Guidance page for the most up to date information.

What is DEERS?

A: A system operated by the Department of Defense and used by TRICARE contractors to determine and confirm the eligibility of beneficiaries. Beneficiaries are responsible for maintaining the accuracy of their DEERS records and updating the system as necessary. You can contact DEERS at 1-800-538-9552.

For more information on DEERS please visit TRICARE DEERS

What is DHA?

A: A Department of Defense field operating activity of the Assistant Secretary of Defense for Health Affairs. The DHA ensures, with the support of the Surgeons General of the Military Departments, that Department of Defense policy on health care is consistently, effectively and efficiently implemented throughout the Military Health System.

For more information on DHA please visit their site at DHA.mil

What is an EOB?

A: A statement sent to beneficiaries and providers showing that claims were processed and the amount paid to providers. If denied, an explanation of denial is provided.

The EOB is confusing. How do I read my EOB and what does all this information mean?

A: WPS TRICARE For Life has developed this simple guide to reading your EOB, complete with easy to understand explanations.

EOB Reference Guide

How do I view my EOB online?

A: You must be a registered user on TRICARE4u.com to view EOBs for the claims we process. If you are already registered you can login at any time in the upper right-hand corner of the site. Once logged in you will be directed to the claims activity area where you can view the EOBs for your processed claims. If you are not a registered user you can register in the upper right hand corner of the site. Once registered you can log-in and view your EOBs in the claim activity area.

I need to print a form from your site. How do I find the form I am looking for?

A: Click here for a list of Forms

What is a grievance?

A: A grievance differs from an appeal or other inquiry in that grievances are usually related to quality of care issues. The grievance system shall allow full opportunity for aggrieved parties to seek and obtain explanation for and/or correction of any perceived failure of a TRICARE approved provider, the health care finder service, or other contractor or subcontractor personnel to furnish the level of care/or service to which the beneficiary believes he/she is entitled. Any TRICARE beneficiary, sponsor, parent, guardian, or other representative who is aggrieved by any failure or perceived failure of the contractor, subcontractor or TRICARE approved providers of service or care to meet the obligations for timely, quality care and service at appropriate levels may file a grievance.

How can I file a grievance?

A: All grievances must be submitted in writing to:

WPS- TRICARE For Life Grievances

P.O. Box 8974

Madison, WI 53708

What is HIPAA?

A: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced to improve portability and continuity of health insurance coverage in the group and individual markets; to combat waste, fraud, and abuse in health insurance and health care delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance; and for other purposes.

How does HIPAA affect me?

A: The HIPAA Privacy Rule establishes in law the basic principle that an individual’s medical information belongs to that individual and, with certain exceptions; covered entities cannot use the information without permission from that individual. (Covered entities are defined as health care providers, health plans, and clearinghouses.)

Personal representatives are people authorized by a beneficiary to receive personal information. TRICARE For Life must treat a personal representative as the individual (i.e., any information that can be released to the individual can be released to the personal representative).

For more information on HIPAA please visit HIPAA

Are incontinence supplies or adult diapers a covered benefit under TRICARE For Life?

A: No. Incontinence pads and adult diapers are not covered. For more information on medical supplies and equipment that is or is not covered please click here.

I’m not sure what my username is for TRICARE4u.com. What can I do now?

A: The first thing you should do is make sure you created an account. If you are sure that you registered in the past, please use our Login Assistance to retrieve the username that you created for the account. Once you retrieve the username you can reset your password in this area as well. If you have not created an account please Create an account.

I forgot my password. What can I do to get logged in?

A: Please use our Login Assistance In this area you can reset your password by providing your username and email address.

I have tried the login assistance and still cannot get logged in. What else can I do?

A: You have four options to contact Customer Service for additional assistance.

1. Live Chat with a Customer Service representative 24/5, from 5 AM Monday through 10 PM Friday CST. You can open a chat from the bottom right of the screen on any page within TRICARE4u.com.

2. Send us an email (Please note that this is an unsecure communication channel and only general information can be provided in this area.)

3. Login go to the Message Center and send us a secure message.

4. Give us a call at 1-866-773-0404. One of our experienced representatives will help!

The system has locked my account. What can I do now?

A: Please use our Login Assistance. In this area you can reset your password by providing your username and email address.

What is Medicare?

A: Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

I need more information on Medicare or I need to enroll. What should I do?

A: Your first step should be to visit them online at Medicare. Their site will provide all of the information you need regarding the Medicare program. You can also contact them by phone at 1-800-633-4227 (1-800-MEDICARE).

I would like to access this web site on my smartphone or tablet. Is this possible?

A: Yes. TRICARE4u.com was developed with a mobile first approach. When you access our site on your mobile device our site will automatically adjust to your device and display in a mobile friendly view. We encourage you to access our site with any device that you have available.

I am environmentally conscious and would like to save paper. Does TRICARE For Life offer an option to no longer send me paper documents?

A. Yes we do. You must be a registered user on TRICARE4u.com to take advantage of this feature. If you are not registered you can Create an account. During the registration process you will be asked if you would like to receive your Explanations of Benefits (EOBs) via e-mail or postal mail. Choose email and all of your EOBs will be sent via email and the paper will be stopped. If you are already registered you can login at any time and go to the Family Profile area. In this area you can change your paperless option at any time.

What is a recoupment?

A: A recoupment is a request for refund when we overpay an account. Some of the most common reasons for a recoupment are:

• We are not aware of a patient’s other health insurance coverage
• We paid the same charge more than once
• We paid on a claim for an ineligible beneficiary
• We paid the wrong health care provider or person

What if I disagree with a recoupment?

A: You may request a review in writing to our recoupment department. Be sure to include any pertinent documentation/information and your reason(s) for disagreeing.

Submit your request to: WPS/TRICARE For Life P.O. Box 7928 Madison, WI 53707-7928

What if I am late sending back my refund and you have started an offset? Will I receive a refund of any money due to me?

A: Yes, we will refund any money owed to you, less any applicable interest. There are some circumstances when we will return your check instead.

What is an offset?

A: The withholding of payment to satisfy a refund request from a previous account.

How long do I have to repay the money?

A: If you are a beneficiary, you have 30 days from the date of the recoupment letter. If you are a provider, you have 60 days from the date of the recoupment letter. If the payment is not received by this time, then we will begin withholding claim payments (offsets).

Why do I need to refund money if the pharmacy received payment?

A: If a recoupment for prescriptions is requested because we received notification the beneficiary has other health insurance and the pharmacy filed the claim electronically, then we recoup against the patient. After filing with your other health insurance and they pay as primary, please send our recoupment department a copy of their Explanation of Benefits with a copy of our recoupment request. Our office will then correctly coordinate with your other health insurances. Please remember, it is the patient’s responsibility to notify the providers of primary other health coverage.

Why did I receive a recoupment request for payments that TRICARE For Life made to the provider?

A: Patients are sent "courtesy copies" of recoupment letters that were sent to their health care provider. If the letter is addressed to your health care provider, then the responsibility to refund our payments is theirs.

Why should I create an account on TRICARE4u.com?

A: There is no cost to register on TRICARE4u.com and you can gain access to your personal information the same day you register. Once registered you can monitor all of your claim activity, view Explanations of Benefits, eligibility details, out of pocket costs, account access information and paperless option, update your Other Health Insurance information and use the Message Center to contact Customer Service. All of this and more in a secure, online environment, which can be used 24 hours/day, 7 days/week. Please create an account and start taking advantage of all we have to offer!

How do I create an account on TRICARE4u.com?

A: Go to our homepage and in the large Login box click the link labeled create an account. The on-screen instructions will walk you through the process from there. Please be aware that you must be registered in the Defense Enrollment Eligibility Reporting System (DEERS) to be eligible for TRICARE For Life and to register on this site.

Is TRICARE4u.com still useful to me if I don’t register?

A: Yes, you can still get valuable information from our site just by going to our homepage. There is a lot of good information on the homepage and in the benefits section as well. The disadvantage of not registering is that you will not see any of your personal information.

What happens when a claim is returned for additional information?

A: There are many reasons why a claim is returned for additional information. If additional information is needed, the entire claim will be returned to the party who submitted it. The claim will be accompanied with a letter detailing the information needed to complete processing. Some of the top reasons that a claim could be returned for additional information are:

• Services required a prior authorization or referral and one is not on file. Medical documentation will be requested so that medical necessity of the services or inpatient admission can be established.
• Other Health Insurance (OHI). As a government program, TRICARE For Life is secondary to most insurance. The only exceptions to this are TRICARE supplemental insurances and Medicaid. If our records indicate a primary insurance and a claim is submitted without evidence of those services being processed by the primary insurance, the claim will be returned.
• The beneficiary is enrolled in another region. The beneficiary’s permanent home address or enrollment within another region determines processing jurisdiction.
• The provider did not properly sign the claim. Signature on file is not an acceptable signature for a provider.

If you are aware of what information is needed, please resubmit that information along with a completed Patient's Request for Medical Payment (DD Form 2642). If you are not sure of the specific reason why the claim was returned, please contact Customer Service through the Message Center on this web site or by phone at 1-866-773-0404.

Is TRICARE For Life active in any social media outlets?

A: Yes we are and we invite you to follow us! Use links below to access Facebook, X and YouTube.

Facebook
X
YouTube

Who is my sponsor?

A: The active duty service member or retiree through whom family members are eligible for TRICARE For Life. Your sponsor number is the service members Social Security Number (SSN).

What action can I take when my claim denies for timely filing?

A: You may submit a request in writing for a timely filing waiver. Please provide details and all supporting documentation you have supporting the reason the claim was not filed within 1 year of the date services were provided. Your timely filing waiver request can be submitted online through the Message Center or by mail to the following address: WPS/TRICARE For Life P.O. Box 7889 Madison, WI 53707-7889 TRICARE For Life

----------- What are valid reasons for not filing in time?

A: If a patient’s eligibility is retroactively determined, or there is evidence to show that the provider or beneficiary was prevented from filing timely based on administrative error, or the patient’s inability to communicate because of physical disabilities or mental incompetence or delays by the other insurance as long as the claim was filed with the other insurance prior to the filing deadline.

Why did my claim deny for timely filing?

A: TRICARE For Life requires that all claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.