FAQs

How do I appeal a denied claim? 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. The appeal must have one of the following EOB denial codes: 004, 005, 006, 008, 009, 010, 012, 013, 014, 015, 016, 019, 022, 023, 025, 026, 027, 031, 032, 035, 037, 041, 050, 052, 053, 057, 059, 061, 062, 067, 122, 138, 153, 154, 206, 277. To file a medical claim appeal, follow the instructions on your Explanation of Benefits (EOB) or determination. 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 Overseas 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 Overseas ATTN: APPEALS P.O. BOX 7992 Madison, WI 53707-7992 Appeals can also be sent to TRICARE Overseas through the Message Center on the TRICARE-Overseas.com website. --- ### Can a "corrected claim" be used as an appeal? Yes. If a beneficiary or provider submits a "corrected claim" that changes the diagnosis and/or procedure code, it will be considered a formal appeal. For more information on the appeals process please visit Compliments, Grievances, and Appeals page. --- ### What kind of denied charges are appealable? 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.

What is a beneficiary and who are my beneficiaries? For the purposes of TRICARE Overseas, 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 the Defense Health Agency site Defense Health Agency site.

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 Enrollment and Eligibility

What is DHA? 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 DHA.mil

The office that manages the Defense Enrollment Eligibility Reporting System (DEERS) database and provides customer service for beneficiaries who are trying to establish, maintain and determine their eligibility for TRICARE. The DMDC also distributes the certificates of creditable coverage to beneficiaries upon loss of eligibility. For more information on DMDC please visit their site at DMDC

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. Understanding your EOB 
----------- How do I view my EOB online? A: You must be a registered user on https://portal.tricare-overseas.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.

You can access forms at Beneficiary forms

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 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

Visit MyCare Overseas FAQS 

I am environmentally conscious and would like to save paper. Does TRICARE offer an option to no longer send me paper documents? A. Yes we do. You must be a registered user on https://portal.tricare-overseas.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.

It is recommended to submit the following information with your physical therapy claims as this information is often required in order to process your claim. - Signed doctor's orders - Initial evaluation - Plan of treatment - Goals exercises/techniques to be rendered to attain the set goals - An anticipated discharge date - If more than one service is rendered, include the cost breakdown for each service

What are valid reasons for not filing a claim timely? Retroactive Determinations: Retroactive Eligibility - In order for an exception to be granted based on a retroactive determination, the retroactive determination must have been obtained/issued after the timely filing period elapsed. If a retroactive determination is obtained/issued within one year from the date of service/discharge, the one year timely filing period is still binding. Administrative Error: 1. If an administrative error is alleged, the contractor shall grant an exception if there is a basis for belief that the beneficiary or provider had been prevented from timely filing due to misrepresentation or mistake of an officer of employee of DHA, or a contractor (WPS), performing functions under TRICARE and within the scope of the individual’s authority. 2. The necessary evidence shall include a statement from the beneficiary or provider, regarding the nature of the error, how he or she learned of the error, when it was corrected, and if and when the claim was previously filed as well as one of the following: A. A written report by DHA or the contractor (WPS) describing how the error caused failure to file within the usual time limit, or B. Copies of a letter from DHA or the contractor (WPS) confirming the error. Note: The statement from the beneficiary or provider is not essential if it can be established that there was an administrative error and that he or she filed the beneficiary or provider filed the claim within 90 calendar days of being notified of the error. Inability to Communicate and Mental Incompetency: Mental Incompetency - Not only does this exception cover mental disabilities, but it also includes the inability to communicate because of a physical disability. A physician's attestation statement is required in this case. The statement must include dates, the diagnosis(es), and treatment. A copy must be submitted with each claim. There must be evidence that no legal guardian was appointed. If a legal guardian was appointed prior to the timely filing deadline, an exception will not be granted. The legal guardian is obligated to file the claim prior to the deadline. Delay in processing by Other Health Insurance 1. The contractor may grant an exception if the beneficiary submitted a claim to the primary health insurance and the OHI delayed adjudication past the TRICARE deadline. 2. The claim must be submitted to the contractor within 90 days from the date of the OHI processed the claim. TRICARE/Medicare Dual Eligibility - Claim Filed Timely with Medicare 1. The contractor may grant an exception if Medicare accepted the claim as timely. 2. The claim must be submitted either by Medicare or by the beneficiary, within 90 calendar days from the date of Medicare processed the claim to be considered for a waiver. 3. The contractor receives a Medicare EOB that indicates they transferred or electronically crossed the claim over to TRICARE. In this case the claim must be received within one year from the process date on the Medicare EOB. *Review “Beneficiary is on Medicare crossover, claim did not crossover” to determine if that scenario would allow waiver. 4. Requested information received within 90 days of our denied or removed date. (Removed for medical notes, denied 136, etc.).