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1) This notice can be used:
If you need more information:
2) Time Limit for Filing Claims:
All claims for benefits submitted under CHAMPUS/CHAMPVA for dates of service prior to January 1, 1993 must be filed with the appropriate CHAMPUS contractor no later than December 31 of the year immediately following the year in which the service or supply was provided. For services on and after January 1, 1993, all claims must be filed with the appropriate TRICARE contractor no later than one year from the date of service or, the date of discharge in the case of inpatient care.
If your claim was denied because it was not filed on time and you believe you were not at fault, contact us or your Health Benefits Advisor for assistance. In limited circumstances, exceptions may be made.
3) Type of Service Codes:
4) Your Right to Appeal This Initial Determination:
If you disagree with the determination on your claim, you have the right to request a 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 this notice. If the postmark on the envelope is not legible, then the date of receipt is deemed the date of filing. Include a copy of this notice. On receiving your request, all TRICARE claims for the entire course of treatment will be reviewed.
5) If Payment Not Based On The Full Amount Billed:
The amount TRICARE may pay is limited by law to the lowest of:
6) Patient's Share of The Cost For Authorized Care:
Claim payments are subject to the provision that the beneficiary cost-share is collected by the provider. The provider's failure to collect the cost-share can be considered a false claim and/or may result in reduction of payment.
7) Sponsor, Patient, or Dependent Not Enrolled or Not Eligible on DEERS:
If the Defense Enrollment Eligibility Reporting System (DEERS) indicates that the sponsor, patient and/or dependent is not enrolled or eligible for TRICARE benefits, you should contact your Health Benefits Advisor or your service personnel office. Future claims will be denied if you are not enrolled in DEERS. If the claim was denied and the sponsor has recently gone on active duty, resubmit the claim with a copy of the duty orders and a photocopy of the patient's identification (ID) card or parent's ID for dependent children under 10 years of age. If the sponsor is retired, resubmit the claim with the sponsor's retirement papers and a photocopy of the patient's (ID) card. If the sponsor is deceased, report to any service personnel office to get enrolled or call the appropriate number listed below.
8) Identification Card (ID) or Eligibility Expired on DEERS:
The Defense Enrollment Eligibility Reporting System (DEERS) indicates that the patient's ID card or eligibility has expired. To get a new ID card or extend eligibility, if sponsor is active duty, report at once to any parent service personnel office; if sponsor is retired or deceased, contact any service personnel office. If the claim was denied, when the patient obtains a current ID card, resubmit the claim with a photocopy of the new ID card (both front and back sides). In an emergency, call the appropriate number listed below.
9) Beneficiary Notice:
Please review the services shown on the front side of this TRICARE Explanation of Benefits. If you find that payment consideration has been made for any services that you did not receive; or that services were provided by a health care professional that you did not see, please call the FRAUD AND ABUSE number at 1-866-773-0404.
10) To File A Grievance:
If you are dissatisfied with the ability of WPS personnel to provide appropriate health care services, access to care, timeliness of care, quality of care or service, or level of care or service, you may file a grievance. Mail your written grievance with supporting information to:
This Claim is in Process
WPS is currently processing the claim. This can sometimes take a few business days depending on the complexity of the claim. Please note that claims with a status of in process may not reflect the correct billed amount of your claim. The correct billed amount will be reflected once your claim is processed.
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Can 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...
Some claims may not be displayed listed here due to the sensitive nature of the diagnosis.
For some examples of sensitive diagnosis claims click here.
- Claims that were returned or declined by other health insurance and thus never sent to TRICARE cannot be shown because we never received the claim.
- Claims that are covered by third party insurance.
- Claims that are too old or too new to show. You can search for claims going back three years.
Wrong billed amount on your in process claim?
Claims with a status of in process may not reflect the correct billed amount of your claim. The correct billed amount will be reflected once your claim is processed.