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Getting to know TRICare Prime and Prime Remote

I see a lot of questions on Navy wife pages related to TRICare Prime. Sometimes people think that TRICare is bad insurance because it is "free through the military." TRICare Prime is not free for dependents. If you are married to an active duty military member and have TRICare Prime, you pay for that insurance. Check out Tricare's Prime Enrollment fees page on their website.

I don't know about you, but if I am paying for a service, I want to use it. Another thing people are very confused about is what exactly TRICare Prime covers. To view the complete handbook, go to TRICare Prime's website and on the right side of the page under "Related Downloads" select "TRICare Prime and TRICare Prime Remote Handbook."

The second page of this handbook will give you a comprehensive list of any phone number you would need under TRICare Prime. When I have a question regarding whether something will be covered or not or if a referral went through or why I am getting a bill for something that will be covered, I immediately call TRICare. And ask. Yes, there are unhelpful people that sometimes answer the phone. What do I do then? Ask to speak to someone else. Or I call back later. One thing I have learned with TRICare is that you will never reach the same person twice when calling their hotline. Since that is my least favorite thing about dealing with TRICare, I love when I live close to a TRICare office. It is wonderful to be able to walk into the office and ask a person-- a real live person with a business card and everything-- specific questions about my insurance or a problem I am encountering.

Now, this blog post is a guideline. Depending on your situation and medical issues, you will probably bump into problems outside of the scope of this post. This will help you understand the basics of TRICare Prime and Prime Remote:
  • You need a PCM (Primary Care Manager). This is an in-network doctor you have on record with TRICare as your PCM. If you live near an MTF (Military Treatment Facility), your PCM will be at the MTF. If you have TRICare Prime Remote, this will be an in-network doctor. Don't know where to begin when finding a PCM? Start at the TRICare homepage. Fill in your information under "Answer Three Questions" (Family member of active duty service member, zip code, TRICare Prime). In the blue toolbar under "My Plan," select "Find a Doctor." Select "Find a network provider." Select "Find a Primary Care Manager." Enter in your information to pull up a list of local PCM's. Now, when I just moved to a new area and have no friends to ask who they recommend and have no idea who I should go with, I take this list and start Googling the practices that pop up and start Googling the PCM's. Usually I can make up my mind on who I want after Googling for a bit. If I'm still stumped, I call TRICare and see who they recommend. The best thing is that if you select a doctor and don't like them, you can change at any time. When I am moving somewhere that has a MTF, I usually go with whoever they assign me to at first. It is easy to change my PCM and, being at a MTF, I can usually ask my neighbors or new friends pretty quickly who they like and don't like at the MTF.
  • Your PCM should always be your first stop/call. Stuck a steak knife in your hand over Thanksgiving? Make an appointment with your PCM to get a referral for an orthopedist. Child has an ear infection Saturday afternoon and your pediatrician is closed? Call your PCMs after hours line and have them verbally say you should go to an urgent care. They may have an urgent care affiliated with their practice and send you there; you may be able to request a specific urgent care you want to go to. The advice nurse will make a note in your file and you can call on Monday and make sure they put in a formal referral to TRICare for your urgent care visit; that way it will be covered. (Don't know what urgent care to go to? Call TRICare and they can tell you or start calling nearby urgent cares and asking if they accept TRICare Prime.) Positive pregnancy test? Achy back? Child with delayed speech? Go to your PCM for each and every referral.
  • To combine the first point and second point, if you happen to switch PCMs while you have a referral in place, you will need a new referral. For instance, if your son has a referral to a speech therapist and you switch pediatricians, you will need your new pediatrician to write a referral to continue seeing his speech therapist; your old referral with your old pediatrician will not cover further visits once you switch.
  • ER visits... Here is what the TRICare Prime handbook has to say on emergency visits:

    "TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a 'prudent layperson' (someone with average knowledge of health and medicine) to believe that a serious medical condition exists; that the absence of immediate medical attention would result in a threat to life, limb, or sight; when a person has severe, painful symptoms requiring immediate attention to relieve suffering; or when a person is at immediate risk to self or others... If a medical emergency occurs, call 911 or go to the nearest emergency room. You do not need to call your PCM or regional contractor before receiving emergency medical care (including overseas care). However, in all emergencies, you must notify your PCM within 24 hours or on the next business day following admission to coordinate ongoing care and to ensure you receive proper authorization."

    Whew! Long winded, but if you feel like you or your child needs to be seen immediately, GO!!!!!!! Call your PCM the next day to let them know what happened and make the appropriate follow up appointments with them. It is also important to note that, say, you go in to the ER because you did stick a steak knife in your hand over Thanksgiving and the ER doctor says, "You need to follow up with Dr So and So at This Orthopedist." That is not a referral; that is a recommendation. You must go to your PCM to get the referral. You can tell your PCM that the ER doctor wanted you to go to a certain orthopedic practice, but if that practice is not in-network, you will have to go somewhere else.
  • Referral issues. Once a referral is written, you can call TRICare and change the doctor or practice anytime before you are seen. So if you get a referral to an orthopedist and you tell them, "I have infant twins and a toddler and have this ginormous cast on my hand. I need to see you now," and they tell you, "Our next available appointment is in three weeks." You can call TRICare and request a different in-network orthopedist. If you have already been to a visit, then you must go back to your PCM and request a different orthopedist and your PCM will write you a new referral. Another problem I bumped into, on Prime Remote, was that our civilian PCMs office was not familiar with TRICare's referral policies (another reason you should be!). They did not realize they could fax in a same day referral. I went in for a referral for an orthopedist and the nurse was filing a regular referral which, once received at TRICare, would processed within 3-5 business days. With a cast on my hand and infant twins, that wasn't good enough. I went back to the office and waited at their office until they faxed in the referral for me and I saw the orthopedist the next day.
  • A good rule of thumb to remember with TRICare Prime is that they will not pay you back. Of course, that is not true, but the process to get a reimbursement is lengthy and tiring. If you are getting billed for something that you know should be covered, call TRICare first. I have received bills for services that were never filed with TRICare. For one reason or another, the doctor's office did not file with TRICare and sent me the bill for the full amount. If TRICare was able to tell me the problem-- such as not filing at all in the first place-- I would then call the billing department at my PCM and say, "Please file that bill with my insurance first." After O's PICU stay, I received a bill for his EKG. Turns out, the hospital billed TRICare one code that included the EKG and the doctor reading the results. In addition to that code, the hospital included two other codes, one code for the EKG and one code for the doctor reading the results (three codes covering the same procedure). TRICare paid for the first code-- the one covering the EKG and the reading of the results-- and declined the last two codes-- the code for the EKG and the code for the reading of the results. The hospital then sent me the bill for the two codes not covered by TRICare. I, of course, did not know that TRICare had already paid for the EKG and the reading of the results. I only knew that I was getting a bill for a procedure that O did receive. I called TRICare to find out what was going on. I was able to get them to explain this to me. I then called the hospital's billing department and explained this to them. They were less than helpful and insisted I needed to pay this bill-- essentially paying for the same service twice. I got off the phone with them and called TRICare back. TRICare then conferenced called the hospital's billing department and explained to them that there was a billing redundancy and that the service-- the EKG and the reading of the results-- had already been paid for and that if I paid the bill they sent me, I would be paying for the service twice. The hospital dropped the bill and the matter was cleared up right then. With Remote, I've had other issues with billing and our civilian providers. When a matter is going to take some to resolve, I always calling the billing department and explain to them that I am working to remedy the situation with my insurance and that the bill will be taken care of one way or another-- either by insurance or by me. When I explain that I received the bill and am working with insurance, the billing department usually makes a note or puts the bill on hold-- stopping it from being sent to a collection agency in the interim. Once, I even had the PCM realize they made a billing error and cancelled the $700 bill they had sent me. Biggest lesson: communicate with TRICare and communicate with the billing department at your PCM.
  • Another good rule of thumb is that if your doctor recommends it, it will be covered. This is especially helpful in an emergency situation. I was very overwhelmed with the tests being ran on O during his PICU stay and kept calling TRICare, "Will this be covered? How about this? And this?" The gal kept telling me, "If they are recommending it, yes, it will be covered." That definitely does not mean kick your feet up and let things work itself out. Keep in contact with TRICare. "I'm going to my OB today for an ultrasound. Will it be covered?" "Our pediatrician is putting in a referral for speech therapy. Will it be covered?" Ask until you know the answer. Keep TRICare's number saved and call at the office before the service is performed if you are uncertain (I have done this. Many times.). Once a procedure is done, someone is getting billed for it. Know your insurance. Know what is covered. Ask if you don't know.
  • The last, and most important point, know who to ask. You will hear many stories from many people. "My son had a toothache and I brought him to the ER. TRICare covered it." "My daughter pinched her finger and I called an ambulance. TRICare covered it." "I went to the urgent care without a referral and TRICare covered it. I didn't have to call my PCM." These are all totally made up and purposefully bogus stories, but you get the idea. People will have these stories about a time that they did something contrary to these guidelines. Yeah, maybe TRICare did cover your daughter's ER visit for her ear infection, but maybe you aren't relaying something key, like you were Remote with no urgent cares nearby. And maybe-- maybe, maybe-- you just really lucked out that somebody at TRICare approved whatever it is you went to the ER for. I have received the EOBs (Explanation of Benefits) from our boys' various urgent care and emergency room visits and it comes down to two things: 1. I would not want to be paying out of pocket for all those expensive visits and 2. we are paying for insurance that covers these visits. Do it right the first time. Call TRICare before you go if you are unsure.
Here are some useful links on the TRICare website:
TRICare has definitely given me a good helping of headaches. We had so many issues when our twins were born and actually continued to receive bills for services received at birth and their first couple weeks up until the time they turned two-- things that I spent hours and hours on the phone with TRICare fixing. It was exhausting and it was not how I wanted to spend my time. But there are things I absolutely love about TRICare Prime and Prime Remote. We never have co-pays. TRICare has covered all our medical expenses. I don't worry about how much the ER will cost us. I don't wonder if our children is sick enough to warrant a visit to the pediatrician. I don't stress over the cost of our monthly medications. I am so grateful for that. We have a family friend who is a cancer survivor on TRICare and all his medical expenses were covered. I just find that fact amazing and wonderful and something to be thankful for. Yes, I've seen doctors at the MTF that I didn't like, that I didn't feel advocated for me or my children. I've also seen civilian doctors out in town who I felt the same way about (and who constantly filed with my insurance wrong). We have also seen doctors that we have loved. We were absolutely blessed by our last pediatrician. We absolutely loved that practice. The best thing I've done as a military wife-- to make our life as a military family easier-- was get to know our insurance.


Fe Adamsonn said…
Thank you for sharing about TRICare Prime in your blog. This will help others to be educated about it. Thanks!

Military spouse scholarship
Kimber said…
Thank you! Glad you found this post to be informative and helpful! :)
Waylon Buser said…
I was under the impression since we served in the military that the coverage was 100% but I was wrong just like you mentioned. You really have to read over your paperwork before getting anything done or you will get a nice little surprise in the mail like I did last month when a bill from insurance came for $300 for a 10 minute visit.

Waylon Buser @ U.S. HealthWorks - Oakland

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