There Is a One Year Deadline to File TRICARE Claims
June 1, 2005
No. 05-18




TRICARE beneficiaries who file their own claims should remember that, with few exceptions, claims must be filed within one year of the date of medical service or from the date of discharge from an inpatient facility. Beneficiaries also have one year from the date they receive medication to file for reimbursement of pharmacy claims. Additionally, the one-year filing deadline applies to those who file on behalf of individuals with other health insurance (OHI).

The deadline applies to TRICARE Standard beneficiaries as well as to TRICARE Prime enrollees who obtain emergency or urgent care outside of the TRICARE region in which they are enrolled. TRICARE Prime and Extra providers are required to file claims on a beneficiary's behalf, and must also meet the one year requirement.

TRICARE beneficiaries who use non-network pharmacies to obtain their prescription drugs pay full price at the pharmacy and then must file a claim to obtain reimbursement. Beneficiaries have many options for obtaining a claim form (DD 2642): from a TRICARE Service Center, Beneficiary Counseling and Assistance Coordinator or Health Benefits Advisor at their military treatment facility; by mail from the TRICARE Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043; or online at www.tricare.osd.mil/claims.

By law, other health insurance (OHI) held by TRICARE beneficiaries must be the first payer for covered benefits, including covered pharmacy services. TRICARE pays first, however, when prescriptions not covered by OHI are covered by TRICARE or when OHI coverage is exhausted. In either case, beneficiaries must obtain an Explanation of Benefits (EOB) from the OHI indicating their OHI does not cover the medication or that the benefit limits of the OHI have been reached. Beneficiaries must submit a DD 2642 form with the EOB, a copy of the itemized bill and, if a drug claim, a copy of the prescription to the appropriate TRICARE contractor for reimbursement.

Exceptions to the one-year timely claims filing deadline apply if one or more of the following situations occur:
The beneficiary was TRICARE-eligible at the time of service, but eligibility was not reflected on the Defense Enrollment and Eligibility Reporting System until after the timely filing limit;

Retroactive preauthorization was received after the timely filing limit expired;

TRICARE Management Activity or the regional contractor made an administrative error;

A legal guardian responsible for managing the affairs of a mentally incompetent patient or a patient who is unable to communicate, was appointed after the timely filing date was reached;

The provider submits the claim as a TRICARE-participating provider after changing from a non-participating provider;

The patient submitted a claim to their OHI in a timely fashion and the insurance plan was responsible for a delay beyond the one-year filing date; or

Medicare accepts TRICARE for Life claims as timely.

For more information on exceptions to the one-year timely claims filing deadline and for claims requirements, beneficiaries may visit www.tricare.osd.mil/claims. For additional information on where to file claims, beneficiaries should go to www.tricare.osd.mil, click on their specific TRICARE region, and obtain information regarding the TRICARE Retail Pharmacy or the TRICARE Mail Order Pharmacy, as appropriate.