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Claims

Claims

Q1:

I have received a non-covered service. How do I receive a service waiver?

A:

Contact your unit representative and the nearest same-service Military Treatment Facility and ask for the Patient Administrator or the Benefit Counseling and Assistance Coordinator. Each should be able to assist.

Q2:

I live in Puerto Rico. Why aren’t my claims getting paid?

A:

In Puerto Rico, all information for eligibility and Line of Duty Determination is processed by Rodriguez Army Health Clinic at Fort Buchanan. Please forward all necessary documentation there.

Q3:

I am Reservist who went to the Emergency Room/Urgent Care after I got off drill/Additional Training orders. Why aren’t my bills paid?

A:

Eligibility is determined by drill attendance rosters and orders. After it ends, you are no longer eligible for care. All care should take place while you are still in duty status. Any claims after eligibility dates must have a Line of Duty Determination and pre-authorization.

Q4:

I was injured overseas and received care at the hospital. How does that get paid?

A:

The TRICARE Overseas Program contractor should process claims for the Continental United States. If you received civilian health care while on orders, traveling, or visiting abroad regardless of where you reside or where you are enrolled, the TRICARE Overseas Program contractor should process the claims. (See TRICARE Operations Manual and refer to Chapter 8, Section 2, paragraph 3.0.)

Q5:

How can I view my claims and authorizations?

A:

You will first need to register for a beneficiary account via the contractor’s portal. You can then view claims, authorizations, and Explanation of Benefits. 

Q6:

Why is Defense Health Agency, Great Lakes not paying my bills?

A:

Defense Health Agency, Great Lakes does not pay claims. When your eligibility is verified, we authorize payment of claims by TRICARE.

Q7:

I am separated/retired but still need Line of Duty care and my authorization is still valid. Why are my claims not getting paid?

A:

When you retire/separate, you lose your Line of Duty eligibility. This also makes your pre-authorization(s) invalid. If you are still receiving care AFTER separation/retirement date, it will be denied. However, you may go to Veterans Affairs for continual care, if you are deemed eligible.

Q8:

How can I request claims reprocessing?

A:

Your unit can contact us via phone at 888-647-6676, option 2, then opt 3. You may also email us at: dha.great-lakes.j-10.mbx.mmso-lod-misc@health.mil. Before contacting us, please ensure you have the billed amount and date of service. Please do not send us bills. 

Q9:

Why does the provider need my Social Security Number when sending claims?

A:

TRICARE uses your Social Security number to verify your eligibility. You may also provide your Department of Defense Benefits Number/DOD Identification Number.

Q10:

I live in one region but received care in a different region. Who should the provider bill?

A:

The provider should bill the region of your Home of Record in the Defense Enrollment Eligibility Reporting System. Your Home of Record should reflect where you currently reside.

Q11:

I am enrolled in TRICARE Prime Remote. How can I get assistance will my bills?

A:

All TRICARE Prime Remote concerns/issues must go through your regional contractor.

Q12:

I am the sponsor, and my dependent is having billing issues. Can you assist?

A:

Defense Health Agency, Great Lakes does not address dependent claims. All dependent concerns must go through your regional contractor.

Q13:

If I have Eligibility on File status why was my claim denied?

A:

There could be several reasons. You can review your Explanation of Benefit or give us a call at 1-888-647-6676 for review.

Q14:

I have a Line of Duty Determination on file somewhere else. Why can’t you just pay my claims?

A:

If our office cannot see or enter your eligibility on file, we cannot authorize claim payments.

Q15:

I am Coast Guard, how do I get my claims reprocessed?

A:

Defense Health Agency does not process claims for Coast Guard. You must contact the Coast Guard Service Point of Contact at 757-628-4379.

Q16:

I am not seeing my claims in the TRICARE portal. Why?

A:

The claim(s) have not been submitted to TRICARE by your provider/hospital. If they need further assistance have them contact your correct regional contractor.

Q17:

I am on Line of Duty plus I have TRICARE Reserve Select. Why are the claims paid as TRS?

A:

The Defense Enrollment Eligibility and Reporting System does not reflect LOD so claims will default to TRS instead of your LOD and/or pre-authorization. If there is a cost-share/copayment associated with that claim, have your unit contact us so we can direct TRICARE to remove the copayments.

Q18:

I am a Reservist with a Dental Line of Duty. What do I do?

A:

Defense Health Agency, Great Lakes does not handle dental claims. All dental claims and Line of Duty information must be routed through United Concordia, at:

United Concordia ADDP Authorization
P.O. Box 69431
Harrisburg, PA 17106-9431

Q19:

How long does it normally take to process my claims?

A:

TRICARE has 30 business days (excluding weekends and holidays). You can track the status on your region’s beneficiary website.

Q20:

TRICARE paid my claims, but I am still getting bills from the providers. What can I do?

A:

Pull a copy of your Explanation of Benefits and contact provider’s billing office about it. If that does not resolve the issue, contact your TRICARE regional contractor and request balance billing letter(s) be sent to the provider.

Q21:

Why is TRICARE requesting refund of payment?

A:

Defense Health Agency, Great Lakes is not involved in recoupments. Please contact your TRICARE regional contractor. You can also contact the TRICARE Health Plan Customer Service Line at 844-204-9351, option 6, for assistance.

Q22:

My provider is unwilling to submit my claims to TRICARE. What do I do?

A:

Please note that  Defense Health Agency, Great Lakes/Military Medical Support Office has no authority to contact private sector providers and direct them to file TRICARE Line of Duty Claims. Contact your regional contractor and request to speak with claims. They should assist on getting providers to bill.

Q23:

Why can’t my provider submit a claim?

A:

Sometimes providers are uncomfortable submitting electronically if the Defense Enrollment Eligibility and Reporting System says you are ineligible for care. If they are unable to submit electronically, then they need send claims to TRICARE via fax or mail using a CMS 1500 form or a UB04 form. These are official insurance claim forms that must be completed by the provider’s office ONLY. 

The provider can manually enter the member’s information: name, sponsor ID/SSN, address, and phone number.

For more information the provider can contact TRICARE directly.

East Region: https://www.humanamilitary.com/provider/

West Region: https://www.tricare-west.com/content/hnfs/home/tw/prov.html 

Q24:

How can I get reimbursed for claims I paid out-of-pocket?

A:

Defense Health Agency, Great Lakes does not reimburse. You must have the provider bill TRICARE and once providers receive payment from TRICARE, it is up to the provider’s office to refund you anything out-of-pocket. 

Additionally, you can submit a claim for reimbursement to TRICARE by going to https://www.tricare.mil/FormsClaims/Claims for more information.

Q25:

The provider billed my private insurance instead of TRICARE. What do I do?

A:

You must have your provider bill TRICARE. Once your provider receives payment from TRICARE, it is up to the provider’s office to refund your private insurance for any payments made on your behalf.

Q26:

I have dual eligibility; I am a TRICARE Prime dependent and a Reservist with Line of Duty. Why are my claims denied?

A:

If you have a Line of Duty, the provider must bill under your own SSN/DBN/DoDID. Line of Duty claims cannot be reprocessed under the incorrect SSN. Authorization is only valid for the Line of Duty condition and if doesn’t match it will be denied.

Q27:

I am getting bills for my Periodic Health Assessments. Why aren’t you paying it?

A:

Defense Health Agency, Great lakes cannot process Periodic Health Assessments as eligibility/Line of Duty care. Learn more: https://www.health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program

Q28:

I received a debt collection notice. What do I do?

A:

First, register for your regional contractor’s beneficiary portal to check if the claim(s) have been submitted to TRICARE. If the claim is in the portal, your unit can contact us to authorize TRICARE to reprocess the claim(s). If the providers have not billed TRICARE, you should provide them TRICARE’s billing information. If further issues persist, you can fill out a debt collection package located on our main website and in our process guide.

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Last Updated: January 30, 2024
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