There are several health coverage policies and plans eligible for cost recovery programs to submit claims. Claim formats that are used in the Military Health System (MHS) are based on encounter services provided, payer requirements, and Service and NCR MD billing policies. The U.S. government may not collect more than the total charge of medical care from any one source or combination of sources. If total payment received exceeds the amount billed, the military treatment facility (MTF) must refund the overage to the payer(s). The table below details the claim format guidelines for each UBO cost recovery program.
- Institutional- Hospital charges (routine service charges associated with hospital stay or ancillary hospital services)
- Professional- Provider charges (professional services provided by a physician or other provider)
| Health Plan/Policy |
Institutional |
Bill format |
Professional |
Bill format |
Cost Recovery Program |
| Private insurance |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
TPC, MSA, MAC |
| Employer Group Health Plan |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
TPC, MSA, MAC |
| High Deductible Health Plan (HDHP) |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
N/A |
| Health Savings Account (HSA) |
No |
N/A |
No |
N/A |
N/A |
| Health Reimbursement Account (HRA) |
No |
N/A |
No |
N/A |
N/A |
| Flexible Spending Account (FSA) |
No |
N/A |
No |
N/A |
N/A |
| Association or Organization Health Plan |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
MAC |
| No fault automobile insurance |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
MAC |
| Third party automobile liability |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
MSA |
| Medicare Supplemental Plan |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
MSA |
| Workers' Compensation Plan (non-federal employee) |
Yes |
8371/UB-04 |
Yes |
837/CMS1500 |
MSA |
| Workers' Compensation Plan (federal employee) |
No |
DD7/DD7A |
No |
DD7/DD7A |
MSA |
| Workers' Compensation Plan (DoD employee) |
No |
N/A |
No |
N/A |
N/A |
| TRICARE Supplement |
No |
N/A |
No |
N/A |
N/A |
| Income (wage) Supplement |
Yes |
N/A |
No |
N/A |
N/A |
| Other/Special Coverage Group |
Yes |
8371/UB-04 |
Yes |
837P/CMS1500 |
TPC, MSA, MAC |
| None (pay patient) |
Yes |
Invoice/receipt |
Yes |
Invoice/receipt |
TPC, MAC |
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Form/Template
2/1/2012
Health Insurance Claim form for Medicare Professional Services.
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Last Updated: September 14, 2015