TRICARE: Take measures to manage other coverages

PHOENIX — OHI: If you don’t know what that means, and you have a private health insurer, you could end up with a claims mess.

OHI stands for Other Health Insurance. This is any health insurance you receive, beyond TRICARE, through an employer or individual plan. Exceptions to this rule are Medicaid, Indian Health Services, other State Funded plans and supplemental insurance policies, which are usually offered by military associations or private companies.

The rules for using OHI with TRICARE differ, depending on if you’re an active duty service member, or a family member. Either way, the moment you begin a health plan using OHI, you need to inform TriWest Healthcare Alliance, your regional TRICARE contractor that administers the TRICARE health benefit throughout 21 western states. TriWest needs to know if you have OHI to coordinate your benefits more smoothly.

If you’re an active duty service member:

TRICARE will always be your primary health plan. You may have OHI with TRICARE, but all active duty service members are required to enroll into TRICARE Prime. Since TRICARE is your main plan, you must follow its rules. It may also be a good idea to read the fine print of any civilian health plan you register for, as many civilian policies exclude members of the active Armed Forces.

If you’re a family member of someone on active duty:

Your OHI is considered your primary health insurance. This means any claims for doctor’s visits, medications, hospital stays and other services are submitted for payment to your OHI first. If any balance remains after your OHI pays, you or your provider can then submit the claim to TRICARE for secondary processing.

Additionally, you must follow all the rules of your OHI plan, including requirements for referrals and authorizations.

Submitting claims with OHI as a family member:

Your doctor’s office will most likely submit your claims for you. If you have OHI, those claims will go to the company that supplies that health coverage first. Once the claim has been processed, you and your doctor will receive a statement — called an “explanation of benefits” — showing the amount paid on the claim.

After you receive that statement, you or your provider can send the claim to TRICARE, for secondary processing. You or your doctor should attach the “explanation of benefits” statement to the claim. If you are submitting your own claims, follow the steps on TriWest’s Claims Portal to properly submit them. This portal will also tell you where to mail your claims: www.triwest.com/beneficiary/claims.aspx .

View your claim status online:

You can now view the status of your TRICARE claims online by registering at http://www.triwest.com and enrolling in the paperless options. Using this secure account, you can receive your referrals and authorizations online, view your out-of-pocket expenses, update your personal information and explore many other online-only benefits. Get started today and visit www.triwest.com/gogreen