Pediatric Coding Alert

Question: We had a patient present with Tricare insurance and we billed the claim to Tricare. A few days later, the parent called to say she forgot to mention she also has commercial insurance through her husband’s job. Do we have to refile with Tricare and the private payer, or can we just send the Tricare EOB to the other payer for the balance?

Answer: Chances are that Tricare is going to deny the claim, assuming that the Tricare office is aware of the patient’s other insurance.

Here’s why: Tricare is always the secondary payer—with a few exceptions. If a particular patient has Tricare as well as insurance through another source, you should almost always consider the other insurance primary. “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.

Therefore, you will most likely find a denial from Tricare for the claim, and you should therefore send it to the other payer instead. Once the commercial insurer pays its portion, you can send the claim to Tricare to see if it will cover any balance on the claim.

Keep in mind that the exception above applies to Medicaid, but not Medicare. Therefore, if you see a disabled pediatric patient who is on Medicare via her disability, 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.