ED Coding and Reimbursement Alert

Question: We had a patient present with Tricare and Medicaid. We know that Tricare is always the secondary payer so we billed Medicaid first and the claim was denied, saying that Medicaid is not primary. Now we’re confused. Can you advise?

Sueprcoder.com Subscriber

Answer: This is an area of billing complexity. Tricare is typically the secondary payer — but there are a few exceptions to that well-known rule, and one exception involves Medicaid.

If a particular patient has Tricare as well as insurance through another source, you should almost always consider the other insurance primary, but that rule changes if the patient has Tricare and Medicaid. “By law, Tricare pays after all other health insurance except for Medicaid, Tricare supplements, state victims of crime compensation programs or other federal government programs (i.e., Indian Health Services),” Tricare says on its website.

Keep in mind that the exception above applies to Medicaid, but not Medicare. Therefore, if you see a patient who is on Medicare but also has Tricare, you should submit the claim to Medicare first, and then the balance bill can go to Tricare. If, however, the patient has both Medicaid and Tricare, bill Tricare first, and then file with Medicaid.  

For more on this issue, see www.tricare.mil/Plans/OHI.aspx.