Elective care vs. non-covered care
December 20, 2013
Lyster Army Health Clinic refers patients out to Tricare-approved network providers when specialty care not offered at the clinic is needed. It is important for patients to receive a referral and only obtain the care detailed in the referral notes to avoid extra charges not covered by the referral.
The specified care must also be received before the referral expiration date. Additional care offered by the network provider must first be approved through Tricare before scheduling an appointment.
Communication is the key to knowing if additional care recommended by the network provider is approved by Tricare. The network provider is responsible for contacting Tricare for approval of additional care not noted on the original referral.
The rules are a little different for active duty Soldiers. Soldiers referred to a network provider who wants to perform additional care for the Soldier must see their Primary Care Manager before accepting additional care. Only their PCM is authorized to submit a new referral for additional care.
Patients are responsible for checking their www.tricareonline.com account to view all approved and disapproved referrals submitted on their behalf. They may also call their PCM, Managed Care at 334-255-7000 ext 3, see a Tricare representative at the Tricare Service Center inside LAHC or call the Tricare toll-free line (1-800-444-5445) to confirm approved referrals. Contacting TRICARE or Managed Care is also how patients can resolve cases where a bill is received that should have been paid or otherwise covered.
Patients who receive additional care without approval will be billed for the total cost of the additional care received.
"Patients often have a procedure or additional care only to find out later that it has been denied either because it is a non-covered procedure or the provider did not provide enough information to Tricare and it wasn't approved," said Sharon Jones, health care system manager at LAHC's Tricare Service Center. "Making sure their network provider receives approval or checking with Tricare themselves can alleviate the financial burden of an unexpected bill."
Non-covered care is care that Tricare will not authorize, pay for, or reimburse. Services received electively, such as cosmetic surgery, and any complications arising months or years after the surgery needing medical attention will not be covered by Tricare unless it is considered life threatening.
Tricare does not reimburse for unproven drugs, devices, or medical treatments and procedures. Services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness are also excluded.
The Tricare Service Center inside LAHC has booklets available for patients interested in finding out which services may be obtained without a referral. Some clinical preventative services and mental health care services for Family members and retirees do not require a referral.
For a full list of what services do not need a referral visit, http://www.tricare.mil/CoveredServices/SeeWhatsCovered/PreventiveServices.aspx. Coverage and out-of-pocket costs may vary based on who you are and your health plan option.