Get smart with claims (East Region)

TRICARE East has tools to help answer your claims questions. Whether you want to submit a claim on your own or have questions about an explanation of benefits, we have resources to help you.

Check out the list of some topics below to find answers to your question. 

Claims process

Q: What happens when a provider makes a claim after an in-person or virtual visit or another type of medical care?

A: Here’s the typical life cycle of an in-network claim:

1. The provider verifies your eligibility and benefits. They do this before your appointment or at check-in.
2. The provider or their office staff assign standardized medical codes to your diagnosis and the care you received.
3. The provider’s staff enters the codes into a standard form and sends to TRICARE East for processing.
4. TRICARE East reviews and evaluates the claim to confirm the service is medically necessary and covered under your plan. They also manage the financial side, applying a cost-share or other health insurance, when applicable.
5. After processing your claim, TRICARE East moves it to reimbursement and billing. TRICARE East sends the payment directly to your provider and issues you an EOB. If a balance remains after TRICARE processes the claim, your provider may bill you for the remaining balance of the TRICARE-allowable charge as indicated on the EOB. You’ll owe this directly to the provider.
6. If TRICARE East denies the claim, your provider will generally correct the errors or provide documentation and refile the claim. If the claim was denied due to something other than clerical errors, you or your provider can file an appeal.

If you want more details about the life cycle of a claim, check out TRICARE East’s Frequently Asked Questions. Think of it as “Claims 101.”

Claim processing

Q: Who’s responsible for submitting claims?

A: Most times, your network healthcare provider will submit claims to TRICARE East. Non-network providers may require you to submit your own claim.

Q: What’s a specialty claim?

A: These include durable medical equipment, breastfeeding supplies, banked donor milk, and some pharmacy claims. Visit TRICARE East Claims for details on how to submit a claim.

Claim status

Q: How do I find the status of a claim?

A: Use beneficiary self-service and the mobile app for iPhone or Android to view the status of a claim. See the beneficiary self-service guide and the TRICARE East mobile app FAQ for more information.

Processing time

Q: What is a typical claim processing time?

A: Claims processing of a complete claim may take up to 90 days from the date TRICARE East receives it. Claims missing required documentation may result in delayed processing.

Appeals

Q: What do I do if I receive a denial?

A: If you disagree with a decision made about your benefits and it involves an appealable denial, you have the right to submit an appeal. The EOB outlines how your claim was handled, what services were covered, and has instructions for starting an appeal. For your convenience, TRICARE East offers an online Appeal self-service tool, which allows you to submit and track your appeal electronically.

Charges and fees

Q: What is the cost-share?

A: This is the portion of the total cost of a covered healthcare service that a beneficiary is required to pay. This applies to beneficiaries enrolled in all TRICARE plans, except active duty service members.

Q: What is the point-of-service option?

A: Point-of-service fees apply if you’re a TRICARE Prime beneficiary, and get certain nonemergency care from a provider without a referral from your primary care manager. These fees also apply when you obtain preventive care, such as a colonoscopy or Pap test, from a non-network specialist. This doesn’t apply to active duty service members.

Find out more about claims and EOBs.