d. Timely Filing of Claims. In order to be considered for benefits, all claims
submitted under TRICARE must be filed with the appropriate TRICARE Contractor no
later than December 31 of the calendar year immediately following the one in which the
covered service or supply was rendered. By failing to file a claim within this prescribed
period, the claimant automatically waives all rights to any benefits for such services
and/or supplies provided during the period affected by the claims filing deadline.
e. Double Coverage. (Medical Affirmative Claims). Where double coverage
exists or where there is third party liability, claims are subject to their provisions.
TRICARE is always "second payor" to all other health insurance plans. "Double
Coverage" means a situation in which a TRICARE beneficiary also has entitlement to
insurance, medical service, health and medical plan, or other government programs
through employment, law, membership in an organization or as a student, which in
whole or in part duplicates TRICARE benefits, but not including entitlement to receive
care from the uniformed services medical care system. Third party liability is covered in
f. Beneficiary Responsibility. The beneficiary is responsible for securing
information about whether or not he resides in a geographical area requiring a non-
availability statement. When a claim is submitted for TRICARE benefits to defray costs
of services for which a non-availability statement was issued, the statement must
accompany the claim.
(1) Cost sharing. The percentage you pay and the part TRICARE Standard
pays of the allowable charges for care on each claim.
(2) Deductible. The amount you must pay on your bills each year toward
your outpatient medical care.
(3) Reasonable charge. The TRICARE-determined level of payment to
physicians, other individual professional providers, and other providers, based on
one of the approved reimbursement methods.
(4) Reasonable cost . The TRICARE-determined level of payment to
hospitals or other institutions, based on one of the approved reimbursement methods.
(5) Excess charge. The amount charged by the provider that exceeds the
reasonable charge determined by TRICARE.
NOTE: The sponsor is responsible for paying the excess charge to the provider.