Claims

General Claims Submission

Typically, health care providers will handle claims submission for TRICARE East beneficiaries. However, if the provider isn't TRICARE-authorized on the service date, the claim will be denied, and you’ll be responsible for the costs if the provider hasn't submitted the necessary certification paperwork.

Submitting Your Own Claim

In certain cases, you can submit your own claim, such as: 

• Services from non-network providers at a doctor's office (e.g., injections, immunizations) 
• Specialty pharmacy items given at a doctor's office, like allergy shots 
• Durable Medical Equipment and supplies 

Claims You Can’t Submit

You can’t file claims for: 

• Institutional charges from network and non-network facilities (e.g., surgery, lab work) 
• Services from network providers, as they must submit claims for you 

Understanding Provider Types

Network Providers: Must submit claims and can accept copayments and cost-shareA percentage of the total cost of a covered health care service that you pay. before services. 

Non-Network Providers: No TRICARE agreement. They can be: 

• Participating: Accept TRICARE payments and TRICARE Maximum Allowable ChargeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges. as full payment. 
• Non-Participating: May charge up to 15% more than TMAC, and you might need to pay upfront. 

Specialty Claims 

Banked Donor Milk Claims

To file a claim for BDM, use a milk bank certified by the Human Milk Banking Association of North America. You need an approved referral from TRICARE East. Submit claims using the infant's name, not the mother’s. TRICARE doesn’t cover shipping costs for BDM. 

Breastfeeding Supplies

Starting May 1, 2023, TRICARE covers 100 breast milk storage bags every 30 days. If you need more than that in a month, you'll need a prescription or Certificate of Medical Necessity from your doctor. 

You can't bill replacement supplies on the same day you buy a breast pump. When you buy a breast pump, it comes with a kit that includes all necessary supplies, as well as an initial set of breast milk bags. TRICARE will cover one kit per birth. You can order breast pump supplies starting at 27 weeks of pregnancy, even before delivery. 

Note: The procedure code for breast milk storage bags is A4287 starting Jan. 1, 2024. The old code, K1005, expired on Dec. 31, 2023, and won't be accepted anymore. 

DME Claims 

TRICARE covers DME like wheelchairs, CPAP machines, and crutches when a doctor prescribes them. To file a claim for DME, include a prescription or a Certificate of Medical Necessity from your doctor. The CMN should specify how long you need the equipment. For rent-to-own DME, the CMN must show a 15-month need. Fax the CMN to 608-221-7542. Note that this doesn’t apply to breast milk storage bags. 

Pharmacy Claims

Send claims for prescription medications to Express Scripts, Inc., PO Box 52132, Phoenix, AZ 85072-2132.