Operation Just Cause... ...for as long as it takes
WASHINGTON, D.C.--Now that TRICARE Regions 1, 2 and 5 are fully implemented, what if you're an active duty member enrolled in another region who's traveling in these regions and you require medical treatment from
a civilian source?
After you get the needed care, you-or the provider who treated you-will file a claim for government reimbursement of the resulting charges. But where should the claim go for processing?
Until national "supplemental" health care (care that active-duty members obtain from civilian sources) modifications are put into effect in all TRICARE regions this fall, either of the following two options for
claims processing may be used in Regions 1, 2 and 5.
Option A: You or your provider may submit the claim directly to the TRICARE claims processing contractor, Palmetto Government Benefits Administrators (PGBA) where it will be priced by PGBA.
Claim forms may be printed from the TRICARE Website.
PGBA will forward the claim to a uniformed service point of contact, such as the Military Medical Support Office (MMSO), an active-duty case management center established jointly by the services to oversee active duty-medical care provided in civilian facilities. The MMSO will determine the responsible military treatment facility (MTF) and send the claim there for payment.
As a readiness effort, MTFs are charged with providing medical oversight for all active-duty members. It is important for military treatment facilities to coordinate the care active-duty members receive
in civilian facilities.
Option B: You or your provider may send the claim to an MTF within Regions 1, 2 or 5. The MTF will submit the claim to PGBA, for pricing. Once the claim is priced, it will be returned to the MTF for payment. Again, this process allows an MTF commander to be knowledgeable of both the care you receive and to administer proper payment for that care.
Under Options A & B, you may have to pay up front for other services you receive outside of the civilian facility. For example, you may need to send in claims to PGBA for pharmacy services. When your claim is
processed, you will receive reimbursement directly from PGBA.
Active-duty military members who reside in TRICARE Regions 1, 2 or 5 will have their claims for "supplemental" care processed and paid directly by PGBA.
Should you be an active-duty member from another region traveling in these regions and require civilian medical care, refer to the following geographic boundaries to determine if you are in TRICARE Regions 1, 2 or
5.
The address for PGBA is provided for each of these regions.
TRICARE Region 1 includes Maine, New Hampshire Vermont, Massachusetts, Connecticut, Rhode Island, Delaware, Maryland, New Jersey, New York, Pennsylvania, the District of Columbia, and small portions of
northern Virginia and eastern West Virginia. Send claims for Region 1 to:
Palmetto Government Benefit Administrators
TRICARE Region 2 includes North Carolina and most of Virginia (except for a small part of northern Virginia that's part of Region 1). TRICARE Region 5 includes Wisconsin, Michigan, Illinois, Indiana, Ohio, Kentucky, the St. Louis area in Missouri, and most of West Virginia (except for a small part of the northeastern corner of the state that's part of
Region 1). Send claims for Regions 2 and 5 to:
Palmetto Government Benefit Administrators Presently, when traveling in the remaining TRICARE Regions (3/4, 6, 7/8, 9, 10, 11, TRICARE Pacific, Latin America/Canada and Europe), you or your provider must send the claim to the nearest MTF. The MTF will
submit the claim to the TRICARE claims processing contractor for pricing. Once the claim is priced, it will be returned to the MTF for payment. Contractors in Regions other than 1, 2 and 5 will not accept claims directly from the
active-duty member's provider or the active duty member.
For more information on filing claims, please see the TRICARE Website and go to Understanding your TRICARE Benefits then Claims-Where to file a Claim. Stay tuned for further information on the active-duty national "supplemental" health care program to be put into effect in all TRICARE regions this fall.
For more information, contact: TRICARE Communications and Customer Service, (703) 681-1775
Sent in by Veterans News and Information Services
TRICARE/CHAMPUS Claims
P.O. Box 7011
Camden, SC 29020-7011.
The PGBA phone number for this region is (800) 578-1294.
TRICARE/CHAMPUS Claims
P.O. Box 7025
Camden, SC 29020-7025.
The PGBA phone number for this region is (800) 493-1613.
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