Everything You Need to Know about Filing Medical Claims

3/1/2019

Did you visit your doctor recently? If you visited a TRICARE network provider, in most cases, your provider will file a claim for you after the visit. In some cases, you may have to pay for health care services upfront and file your own claim to get money back. It’s important to know when you need to file a claim and how to do so.

A claim is a request for payment from TRICARE that goes to your regional contractor after you get a covered health care service. If you also have Medicare, the claim will go to a Medicare contractor.

When Do I Need to File My Own Claims?

If you’re enrolled in TRICARE Prime or TRICARE Prime Remote, you usually don’t need to file claims for health care services. In most cases, your provider will file claims for you. If you’re enrolled in TRICARE Select, network providers will file claims for you. But if you get care from a non-network provider, you may have to file your own claims. You should also expect to file your own claims to get money back if you have TRICARE Overseas Program (TOP) Select. 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. You don’t need to file claims when using the US Family Health Plan.

Typically, you must file your own claim if: 

  • You receive services from a non-network provider or pharmacy, or use a civilian pharmacy overseas.
  • You get care outside of the U.S. 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 get care from a Medicare non-participating provider. 
  • You have other health insuranceClick to closeHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance." (OHI) in addition to Medicare and TFL.           

Your claim must include all required information when you file it.

How do I File a Medical Claim?

For all stateside claims, download and submit your completed medical claim form (DD Form 2642) and supporting information (for example, a copy of the provider’s bill) to your TRICARE regional contractor. Do this as soon as possible after you receive care.

For overseas claims, submit the claim form and proof of payment to the TOP claims processor in the region where you received care. You may file overseas claims online through the secure claims portal on the TOP website. Video tutorials are also available to help guide you through the overseas claims process.

If you have TRICARE For Life, TRICARE pays last after Medicare and other health insurance. If you do have OHI in addition to Medicare and TFL, submit DD Form 2642, a copy of your provider’s bill, Medicare Summary Notice, and OHI explanation of benefits to the TFL contractor, Wisconsin Physicians Service – Military and Veterans Health (WPS). If you get care overseas, TFL is the primary payer, unless you have OHI. You should also file claims in the overseas area where you received care. Visit the claims section in the TRICARE For Life Handbook for more details about filing health care claims stateside and overseas. Claims filing instructions for TFL are also available on the WPS website.

When Should I Submit Claims?

File claims as soon as possible to help avoid delays in payment. In the U.S. and U.S. territories, you must file your claim within one year of the date that you received medical services. Overseas, you need to file your claim within three years. Remember, you’ll need to submit a proof of payment with all overseas claims.

Avoid Delays in Processing Your Claim

To avoid delays, follow these claim filing tips to help you fill out the claim form correctly and attach all required documents. Remember, you can always contact your claims processor or regional contractor for help with filing a claim, to check a claim status, or to get more information about denied claims.

In most cases, you don’t have to file your own health care claims; your provider will file the claim for you and you’ll be able to view your explanation of benefits online. Learn more about how to file medical claims and check the status of claims on the TRICARE website. You can also review the claims process for pharmacy claims and dental claims.

Last Updated 3/8/2019