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TRICARE For Life

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Important Notice Regarding Change in Timely Filing of TRICARE Claims for Participating Provider Claims.

TRICARE requires that all claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.

Effective February 1, 2010, the claims filing deadline also applies to claims submitted by participating providers. Previously the claims filing deadline was only applied to claims submitted by non-participating providers or TRICARE beneficiaries. In accordance with the TRICARE Operations Manual, Chapter 8, Section 3, there are limited circumstances in which the contractor may waive the claims filing deadline. All requests for exceptions to the claims filing deadline must be submitted in writing.

Please submit all outstanding TRICARE for Life claims prior to the one year filing limit.

For more information, please refer to the TRICARE Operations Manual at http://manuals.tricare.osd.mil/.

Prior Authorization Requirements for TRICARE for Life Beneficiaries

Prior authorization is required for some services when TRICARE for Life (TFL) is the primary payer instead of Medicare.

All services listed below must be reviewed by WPS/Tricare for Life (TFL) for medical necessity and require prior authorization when TRICARE is primary payer instead of Medicare. As secondary payer to Medicare, WPS/TFL will rely on Medicare's determination and NO authorization is required.

If you have authorization from a TRICARE Managed Care Support Contractor (Triwest, Humana or Health Net Federal Services) that cover the dates on your claim, we will honor those authorizations and NO TFL authorization is required. A ten percent payment reduction will apply to a provider's failure to obtain a required authorization.

  • Adjunctive dental care
  • Dental anesthesia and institutional care
  • Inpatient mental health services
  • Partial Hospitalization
  • Psychoanalysis
  • All outpatient psychotherapy after the first 8 sessions in a fiscal year
  • Organ and stem cell transplants
  • Hospice
  • Extended Care Health Option (ECHO)
  • Skilled Nursing

Please fill out the TRICARE For Life Authorization Request Form and submit to the fax number given in the top right corner of the form.

Answering TRICARE For Life (TFL) Claims Questions

The TRICARE For Life (TFL) program is TRICARE's supplement to Medicare and is administered by Wisconsin Physicians Services (WPS). For claims information you should contact WPS' TFL Customer Service through the secured portal by registering an account on TRICARE4u.com. You can also reach them by phone at 1-866-773-0404.

The following information provides an overview of the TFL program to answer some basic questions on how the program operates as well as offering various TFL resources. TFL program highlights

  • TFL is available to TRICARE/Medicare dual-eligible beneficiaries regardless of age, including retired members of the National Guard and Reserve who are in receipt of retired pay, family members, widows/widowers, and certain former spouses. Dependent parents and parents-in-law are not eligible for TFL.

  • TFL coverage is effective the same day that a beneficiary's Medicare Part B coverage becomes effective. If the beneficiary is under 65 and is an Active Duty Family Member (ADFM), no Medicare Part B coverage is required.

  • TFL acts as a supplement to Medicare so providers should file their claims with Medicare first. Medicare will then electronically forward the claim to WPS for processing with the following exceptions:

    • A claim initially denied by Medicare then subsequently paid by Medicare.

    • A claim for which there was also a Medicare supplement as Medicare crosswalks the claim only once.

  • TFL coverage is effective the same day that a beneficiary's Medicare Part B coverage becomes effective. If the beneficiary is under 65 and is an Active Duty Family Member (ADFM), no Medicare Part B coverage is required.

  • Most of the time, both Medicare and TRICARE cover the benefit and Medicare will be the primary payor, paying its portion with TFL paying the outstanding Medicare patient responsibility.

    • When TRICARE is the primary payor, e.g., when both programs cover the benefit but Medicare's benefit is exhausted, TFL will pay the claim according to TRICARE Standard program guidelines or according to TRICARE Prime program guidelines for eligible dual-eligible under age 65 enrolled in Prime.

How TFL Works

The provider first files claims with Medicare. Medicare pays its portion and electronically forwards the claim to WPS, the TFL claims processor. WPS sends its payment for TRICARE-covered services directly to the provider. Beneficiaries receive a Medicare Summary Notice from Medicare and a TFL explanation of benefits (EOB) from WPS indicating the amounts paid. Providers receive an EOB from WPS.

  • For services covered by both TRICARE and Medicare, Medicare pays first and TRICARE pays its share of the remaining expenses second.

  • For services covered by TRICARE but not by Medicare, such as care received overseas, Medicare pays nothing and TRICARE becomes the primary payer. The beneficiary is responsible for the TRICARE fiscal year deductible and cost-shares.

  • For services covered by Medicare but not by TRICARE, such as chiropractic services, Medicare is the primary payer and TRICARE pays nothing. The beneficiary is responsible for Medicare deductibles and cost-shares.

    • For services not covered by Medicare or TRICARE, such as cosmetic surgery, the beneficiary is responsible for the entire bill.

Other Health Insurance

TRICARE/Medicare beneficiaries with other health insurance (OHI), such as a Medicare supplement or employer-sponsored health plan, may also use TFL. By law, TRICARE pays claims only after an OHI plan has paid.

Typically, after Medicare processes a claim, the claim is forwarded to the beneficiary's OHI. Once the OHI processes the claim, the beneficiary or the provider will need to file a paper claim with TRICARE for any out-of-pocket expenses. TRICARE may reimburse the beneficiary for services covered by TRICARE.

TFL Referrals and Authorizations

Because Medicare is the primary payer, there is usually not a requirement for providers to obtain referrals or prior authorization from TriWest. If Medicare benefits are exhausted, or if the patient is seeking care covered by TRICARE but not Medicare, you may need an authorization from TriWest when applicable.

Skilled Nursing

TRICARE has also adopted Medicare's Skilled Nursing Facility (SNF) Prospective Payment System (PPS) payment methods and rates, including Minimum Data Set (MDS) assessments, Resource Utilization Group (RUG) - III classifications, and Medicare weights and per diem rates for all SNF admissions on or after August 1, 2003. Below are a few SNF program highlights, for a on line tutorial and additional SNF information please visit the WPS TFL website at www.tricare4u.com.

  • Coverage: For days 1 to 20, Medicare pays 100 percent. For days 21 to 100, Medicare covers all costs, except for the required Medicare copayment. TRICARE for Life covers the copayment. After day 100, TRICARE is the primary payer and the beneficiary pays TRICARE beneficiary cost shares.


  • Participation Agreement: For a beneficiary who is both Medicare and TRICARE eligible, TRICARE can pay secondary for a SNF that participates in Medicare and has entered into a Participation Agreement with TRICARE. Upon exhaustion of Medicare benefits, TRICARE may pay primary to such SNFs.


  • Medical Necessity: Services billed under the lower 18 RUG codes do not automatically qualify for SNF coverage. Claims submitted with a lower 18 RUG code or with the default HIPPS code AAA00 will require medical documentation. In addition, even with higher level RUG codes TFL will require medical records to determine medical necessity once the patient has been at the SNF for one year.


  • Peer Review: Subsequent reviews are done beyond the initial Medical Advisor reviewed dates to ensure the level of care is appropriate and medically necessary. This does not necessarily mean a Medical Advisor reviews each subsequent month, but each month beyond the original review dates are subject to review by TFL Medical Review staff. Appropriate medical documentation is needed and or requested to support that the level of care has not fallen to a non skilled level.

How to Identify TFL Beneficiaries

Each TFL beneficiary must present a valid uniformed services ID card, as well as a Medicare card, prior to receiving services. You should copy both sides of the cards and retain the copies for your files. There is no TFL ID card. To verify TFL eligibility, simply register an account on TRICARE4u.com. That will give you access to the secure portal where you can log-in to verify patient eligibility. You can also contact Wisconsin Physicians Service (WPS) by phone 1-866-773-0404. You may call 1-800-772-1213 to confirm a patient's Medicare status.