Falls Church, VA, May 11, 2021 - Are you getting ready for a doctor’s visit? One of the best ways you can prepare is by understanding your health care costs and if you need to pay anything out of pocket. When you see a TRICARE network provider, the provider will submit the claim on your behalf. But in some cases, like when you see a non-network provider, you may have to pay for health care services up front and file your own claim to get reimbursed. It’s important to know when you need to file a claim and how to do so.     
 
When should I file a medical claim?  
A claim is a request for payment from TRICARE that goes to your TRICARE contractor after you get a covered health care service. What determines whether or not you need to submit one is your TRICARE plan and provider. As a rule of thumb, you should expect to file your own claims if:

• You get care from a non-network provider.

• You have TRICARE Overseas Program (TOP) Select.

• You travel and get care outside of the U.S., U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands), or overseas. (There are exceptions overseas depending on your health plan and the type of provider you see.)

• You use TRICARE For Life (TFL) and have other health insurance (OHI) in addition to Medicare.       

 
If you’re unsure about how your claims will be filed, check with your provider to find out if you need to submit a claim after receiving care. As stated in the TRICARE Choices in the United States Handbook, “A provider must be TRICARE-authorized for TRICARE to pay any part of your claim.” If you have both Medicare and TRICARE, your claim will go to a Medicare contractor. You don’t need to file claims when using the US Family Health Plan.
 
How do I file a medical claim?
This process depends on where you received care. If you’re filing a stateside claim, submit your completed medical claim form (DD Form 2642) and supporting information to your TRICARE contractor. In the U.S. and U.S. territories, you must file claims within one year of service or the date of inpatient discharge.
 
For overseas claims, submit the claim form and proof of payment to the TOP claims processor. You must file overseas claims within three years of service or the date of inpatient discharge. The simplest way to file overseas claims is to do it online. You just need to log in to the beneficiary secure claims portal. If you need help, there are video tutorials to help guide you. If you’re enrolled in or live in the U.S. and receive care while traveling overseas, you’ll file your claim and proof of payment to the TOP claims processor.
 
Do you have TRICARE For Life? In most cases in the U.S. and U.S. territories, your provider files your health care claims with Medicare. After paying its portion, Medicare sends the claim to the TFL contractor to process, unless you have OHI. If you have OHI in addition to Medicare and TFL, you’ll need to file a claim with TRICARE for reimbursement of any remaining balance. As outlined in the TRICARE For Life Handbook, you’ll need to submit DD Form 2642, a copy of your provider’s bill, the corresponding Medicare Summary Notice, and OHI explanation of benefits to the TFL contractor.
 
For care received overseas, Medicare and the TFL contractor don’t process your claims. You should file your claim along with proof of payment with the TOP claims processor. Refer to the handbook for more details about filing TFL claims for care received overseas.
 
How do I check the status of my medical claim?
If you want to check the status of your medical claim, you can do so online. You must first register on your claims processor’s website. Once you do that, you’ll be able to see where your claim is in the process. You can also view your explanation of benefits, out-of-pocket expenses, and more after registering online. Keep in mind, most claims are processed within 30 days.
 
For more on how to file medical claims, visit Filing Claims. There, you can also learn about other types of claims, including pharmacy and dental. And be sure to listen to the “Get to Know TRICARE” podcast episode, Help! How to File Claims, for more helpful claim filing tips.