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Debt Collection Assistance Officer(DCAO), 23Deductible, 8–10, 12, 18DCenters for Medicare & MedicaidServices, 4Certificate of creditable coverage, 26–27Charge, 8–9, 12, 22, 29Children, 26–27, 30Claim, 1, 7–10, 12–14, 17–18, 20–23, 28Common Access Card (CAC), 17, 24–25Continued Health Care Benefit Program(CHCBP), 26Copayment, 8, 17–19Cost-share, 8–10, 12, 18Custodial care, 16CBehavioral health care, 14Beneficiary Counseling and AssistanceCoordinator (BCAC), 23, 28Bill, 5–6, 8, 12, 22–23, 27Brand-name drug, 19BAccident, 23Active duty family member (ADFM),4–5, 12Active duty service member (ADSM),4–5, 12, 15, 17, 24Active duty sponsor, 11, 16Acupuncture, 15Age limitations, 19, 26Allowable charge, 8, 12, 29Appeal, 8, 21–23, 28–29Appointment, 11–12, 14, 29Authorization, 11, 14, 16, 19, 22, 28–29AIndex32Health Net Federal Services, LLC(Health Net), 14Hearing aids, 15Home health care, 4–5HGeneric drug, 17, 19Generic equivalent, 19Grievance, 30Guardian, 30GFederal Employees Health Benefits(FEHB), 11Former spouse, 4, 11, 22, 25, 27FEligibility, 1, 4–7, 11, 13, 15–16, 22,24–27, 29–30Emergency, 13–14End-stage renal disease (ESRD), 4–5Enrollment, 4–7, 11–13, 17, 24, 26–27Explanation of benefits (EOB), 22–23,28–29Express Scripts, Inc. (Express Scripts),17–21Eye examinations, 15EDefense Enrollment Eligibility ReportingSystem (DEERS), 7, 24–27Defense Manpower Data Center SupportOffice, 27Delta Dental of California(Delta Dental), 16Dental care, 13–14Dependent child, 27, 30Disability, 4–5, 14, 26–27Divorce, 5, 7, 25–27Durable medical equipment, 5TFL provides comprehensive health carecoverage. You have the freedom to seekcare from any Medicare-participating ornonparticipating provider, or militarytreatment facility on a space-availablebasis. Medicare-participating providersfile your claims with Medicare. Afterpaying its portion, Medicare automaticallyTRICARE For Life (TFL) is theMedicare-wraparound coverage forTRICARE beneficiaries who haveMedicare Part A and Medicare Part B,regardless of age or place of residence.1This handbook will help you make themost of your TFL coverage. You will findinformation about eligibility requirements,getting care, and claims. This handbookalso provides details about your pharmacyand dental coverage options.forwards the claim to TRICARE forprocessing (unless you have other healthinsurance [OHI]). TRICARE pays afterMedicare and OHI for covered healthcare services.Welcome to TRICARE For Life

5.4.3.2.231LIST OF FIGURESDebt Collection Assistance Officers .23SECTION 8FOR INFORMATION AND ASSISTANCEExplanation of Benefits .23Third-Party Liability .23Appealing a Claim or Authorization Denial.22Health Care Claims .22Claims . 22Pharmacy Claims .20Pharmacy Policy .19Filling Prescriptions .17Prescription Drug Coverage .17Pharmacy . 17Frequently Asked Questions: TRICARE For Life Coverage .16Dental Coverage .15TRICARE Medical Coverage .15TRICARE For Life Coverage . 15Prior Authorization for Care .14Behavioral Health Care .14Urgent Care .13Emergency Care .13Finding a Provider .12Getting Care . 12Frequently Asked Questions: How TRICARE For Life Works .10How TRICARE For Life Works with Medicare.7Frequently Asked Questions: Medicare .6Understanding Medicare .4Eligibility .4TRICARE For Life Out-of-Pocket Costs . 9MTF Appointment Priorities . 12TRICARE Pharmacy Home Delivery Registration Methods .18Eligibility Requirements for Former Spouses .25TRICARE For Life Appeals Requirements .29Figure 1.1Figure 2.1Figure 4.1Figure 6.1Figure 7.11.How TRICARE For Life Works . 4List of FiguresTable of ContentsSECTION 7

Practices related to patient safety The performance of any part of the healthcare delivery system The demeanor or behavior of providersand their staff members The quality of health care or services(e.g., accessibility, appropriateness,level, continuity, timeliness of care)Grievances may include such issues as:Grievances are generally resolved within60 days of receipt. Following resolution,the party that submitted the grievance isnotified of the review completion.The TFL grievance process provides theopportunity to report, in writing, anyconcern or complaint regarding healthcare quality or service. Any TFL civilianor military provider; TFL beneficiary;sponsor; or parent, guardian, or otherrepresentative of an eligible dependentchild may file a grievance. WPS isresponsible for the investigation andresolution of all grievances.A grievance is a written complaint orconcern about a non-appealable issueregarding a perceived failure by anymember of the TFL health care deliveryteam, including TRICARE-authorizedproviders or military providers, to provideappropriate and timely health care services,access, or quality, or to deliver the properlevel of care or service.Filing a Grievance30Contact Medicare to file Medicare-relatedgrievances. Any appropriate supporting documents Details describing the event or issue Nature of the concern or complaint Address of the event Name(s) of the provider(s) and/orperson(s) involved Date and time of the eventA description of the issue or concern mustinclude the following: Beneficiary’s signature Beneficiary’s date of birth Sponsor’s SSN or DBN Beneficiary’s name, address, andtelephone numberWhen filing a grievance, include thefollowing information:Index . 329.3See the inside back cover of this handbook for “TRICARE Expectations for Beneficiaries.”List of Figures . 31Filing a Grievance .30Your Right to Appeal a Decision .28Beneficiary Counseling and Assistance Coordinators .28For Information and Assistance . 28Suspension of Social Security Disability Insurance .27Loss of Eligibility .26Survivor Coverage .26Moving .26Children .26Getting Married or Divorced .25Using milConnect to Update Information in DEERS.24Life Changes: Update Your DEERS Record . 248.7.6.

4 Any age with end-stage renaldisease (ESRD) Qualifying former spouse You are an active duty service member(ADSM) or active duty family member(ADFM) (ADSMs and ADFMs remaineligible for TRICARE Prime andTRICARE Standard and TRICAREExtra options while the sponsor is onactive duty. However, when the sponsorretires, you must have Medicare Part Bto remain TRICARE-eligible. See“Medicare Part B [Medical Insurance]”on the following page for informationMedicare Part A covers inpatient hospitalcare, hospice care, inpatient skilled nursingfacility care, and some home health care.The Social Security Administration (SSA)determines your entitlement to MedicarePart A based on your work history or yourspouse’s work history. You are eligible forpremium-free Medicare Part A at age 65if you or your spouse has 40 quartersor 10 years of Social Security-coveredemployment.Medicare Part A (Hospital Insurance) Under age 65 with certain disabilities Survivor of a deceased sponsor Medicare Part B coverage is not requiredto remain TRICARE-eligible if: Age 65 or olderMedicare is a federal entitlement healthinsurance program for people:TFL is managed by the Departmentof Defense. Medicare is managed bythe Centers for Medicare & MedicaidServices (CMS). The two agencies worktogether to coordinate benefits.Understanding MedicareNote: Regardless of age, ADFMs who haveMedicare Part A may enroll in TRICAREPrime if they live in a TRICARE PrimeService Area (PSA). The TRICARE Primeenrollment fee is waived for retiree familymembers with Medicare Part B coverage.about the Medicare Part B specialenrollment period for ADSMs andADFMs.) Medal of Honor recipient or eligiblefamily member Family member of a retiredservice member Retired service member (includingretired National Guard and Reservemembers drawing retirement pay) Medicare Part B coverage is required toremain TRICARE-eligible if you are a:When you are entitled to premium-freeMedicare Part A:TRICARE Eligibility RequirementsTRICARE For Life (TFL) is available toTRICARE beneficiaries, regardless of ageand place of residence, if you have MedicarePart A and Medicare Part B. You are eligiblefor TFL on the first date that you have bothMedicare Part A and Medicare Part B.EligibilityHow TRICARE For Life WorksFigure 7.1There must be an amount in dispute to file an appeal. In cases involving an appeal of adenial of an authorization in advance of receiving the actual services, the amount indispute is deemed to be the estimated TRICARE-allowable charge for the servicesrequested. There is no minimum amount to request a reconsideration.529An appeal must be filed within 90 days of the date on the explanation of benefits or denialnotification letter. Denial of treatment plan when an alternative treatment plan is selected Denial of services from an unauthorized provider Eligibility Allowable chargesThe issue in dispute must be an appealable issue. The following are not appealable issues:The appeal must be submitted in writing.Note: Network providers are not appropriate appealing parties, but may be appointed asrepresentatives, in writing, by you. An attorney files an appeal without specific appointment by the proper appealing party A custodial parent submits an appeal on behalf of a minor beneficiaryIf a party other than those listed above submits the appeal, you will generally be requiredto complete and sign an Appointment of Representative form, which is available on yourregional contractor’s Web site. Appeals submitted without this form will not be processed,except in the following cases: Non-network participating providers You, the beneficiary4231 Any appropriate supportingdocuments A copy of the previous denialdetermination notice The specific issue in disputeA description of the issue or concernmust include:An appropriate appealing party must submit the appeal. Proper appealing parties include:TRICARE For Life Appeals Requirements Beneficiary’s or appealing party’s signature Beneficiary’s date of birth Sponsor’s Social Security number (SSN)or Department of Defense BenefitsNumber (DBN) Beneficiary’s name, address, andtelephone numberAppeals should contain the following:SECTION 7FOR INFORMATION AND ASSISTANCE

Any services or supplies denied payment byMedicare and appealable under Medicareare not considered for coverage by TFL.However, if a Medicare appeal results insome payment by Medicare, TRICAREconsiders coverage as the second payer.For more information on Medicare appeals,read the back of your Medicare Summarynotice or contact Medicare.Medicare DenialsMedicare and TFL have separate claimsprocesses. For most services, Medicare isyour primary payer. If you want to appeala Medicare decision, you must contactMedicare. Contact Wisconsin PhysiciansService (WPS) to appeal TFL decisions.If you believe a service or claim wasdenied improperly, in whole or in part,you (or another appropriate party) mayfile an appeal. An appeal must involvean appealable issue. For example, youhave the right to appeal Medicare or TFLdecisions regarding claims payments.Your Right to Appeal a DecisionTRICARE Beneficiary Counseling andAssistance Coordinators (BCACs) canhelp you with TRICARE For Life (TFL)questions and concerns, and they can adviseyou about obtaining health care. BCACsare located at military treatment facilitiesand TRICARE Regional Offices. To locatea BCAC, visit the online directory atwww.tricare.mil/bcacdcao.Beneficiary Counseling andAssistance Coordinators28Prior authorization denial appeals may beeither expedited or non-expedited, dependingon the urgency of the situation. You or anappointed representative must file for anexpedited review of a prior authorizationdenial within three calendar days of receiptof the initial denial. A non-expedited denialreview must be filed no later than 90 daysafter receipt of the initial denial.TFL appeals must be filed with WPSwithin 90 days from the date that appearson the explanation of benefits or denialnotification letter. If you are not satisfiedwith a decision rendered on an appeal,there may be further levels of appealavailable to you. Your TFL appeal mustmeet the requirements listed in Figure 7.1on the following page. For specificinformation about filing a TFL appeal,contact WPS.Filing TRICARE For Life AppealsWhen services are denied based on medicalnecessity or a benefit decision, you areautomatically notified in writing. Thenotification includes an explanation of whatwas denied or why a payment was reducedand the reasoning behind the decision.You may appeal a TFL denial of a requestedauthorization of services even if no care wasprovided and no claim was submitted. Thereare some things you may not appeal. Forexample, when TFL is the primary payer,you may not appeal the denial of care froma provider who is not TRICARE-authorized.TRICARE For Life AppealsRequirementsFor Information and AssistanceMedicare allows ADSMs and ADFMs whoare entitled to Medicare based on age ordisability (does not apply to those with ESRD)to delay Part B enrollment and sign upduring a special enrollment period, whichwaives the late enrollment surcharge. Thespecial enrollment period for ADSMs andADFMs is available any time the sponsoris on active duty or within eight monthsfollowing either (1) the sponsor’s retirementor (2) the end of TRICARE coverage,whichever comes first. To avoid a break inMedicare Part B covers provider services,outpatient care, preventive care, homehealth care, and durable medical equipment.Medicare Part B has a monthly premium,which may change annually and variesbased on income. If you sign up after yourinitial enrollment period for MedicarePart B, you may have to pay a monthlypremium surcharge for as long as youhave Medicare Part B. The surcharge is10 percent for each 12-month period thatyou were eligible for Medicare Part B butdid not enroll.Medicare Part B (Medical Insurance)If, when you turn 65, you are not eligible forpremium-free Medicare Part A under yourown Social Security number (SSN), youmust file for benefits under your spouse’s(this includes divorced or deceased spouses)SSN, if he or she is 62 or older. If your spouseis not yet 62, you should enroll in MedicarePart B at age 65 to avoid paying a surchargefor late enrollment, and you should file forPart A benefits under your spouse’s recordwhen he or she turns 62.5If you return to work and your SocialSecurity disability payments are suspended,your Medicare entitlement continues forup to eight years and six months. Whenyour disability payments are suspended,you will receive a bill every three monthsfor your Medicare Part B premiums.You must continue to pay your MedicarePart B premiums to remain eligible forTRICARE coverage.If you receive disability benefits from theSSA, you are entitled to Medicare in the25th month of receiving disability payments.The CMS will notify you of your Medicareentitlement date.Medicare Entitlement Based ona DisabilityNote: If you have ESRD, sign up forMedicare Part A and Part B as soonas you are eligible to avoid a break inTRICARE coverage and the MedicarePart B late-enrollment premium surcharge.coverage, ADSMs and ADFMs must sign upfor Medicare Part B before sponsors retire.SECTION 1HOW TRICARE FOR LIFE WORKS

Your Part B premiums are automaticallytaken out of your Social Security orRailroad Retirement Board checks. If youEnroll in Medicare Part

TRICARE For Life Handbook TRICARE For Life Wisconsin Physicians Service www.TRICARE4u.com 1-866-773-0404 TRICARE North Region Health Net Federal Services, LLC www.hnfs.com 1-877-TRICARE (1-877-874-2273) TRICARE South Region Humana Military, a division of Humana Government Business Humana-Military.com 1-800-444-5445 TRICARE West Region UnitedHealthcare Military & Veterans www.uhcmilitarywest .