Other Health Insurance (OHI)

Active Duty Service Members

TRICARE is the primary payer for active duty service members, including activated National Guard and Reserve members. These members should not use OHI as their primary coverage. TRICARE is primary and does not coordinate benefits with other insurers.

All Other Beneficiary Categories

TRICARE and OHI work together to coordinate benefits for payment. By law, TRICARE pays after their OHI. If a beneficiary has health coverage through an employer, private insurer, or school, their OHI is always their primary insurance and would pay before TRICARE. If TRICARE receives the claim before OHI processes it, TRICARE will deny it. Please see the exceptions below where TRICARE would pay first (not all-inclusive):

  • Medicaid
  • Medicare
  • State Victims of Crime Compensation Programs
  • Department of Veterans Affairs (DVA)
  • Veterans’ Health Administration (VHA)
  • Maternal and Child Program
  • Indian Health Service
  • TRICARE supplements

If you believe TRICARE has erroneous OHI record(s), please contact the beneficiary to update their OHI.

Reimbursement

To learn more about how payments are calculated with OHI, please review TRICARE Reimbursement (TRM) Chapter 4, Section 2 and 3.

TRICARE and Secondary Payment

If TRICARE is the secondary payer after OHI, providers must submit claims to the primary payer before billing TRICARE. Fill out the appropriate Coordination of Benefits (COB) loops and segments on electronic claims submissions. Include the OHI Explanation of Benefits (EOB) with paper claim submissions.

TRICARE requires an acceptable reason from OHI for non-payment before a claim can be considered payable. To coordinate benefits, the EOB/COB must reflect the following:

  • The beneficiary’s liability (copayment, deductible, and/or cost-share)
  • Original billed amount
  • Allowed amount
  • Any discounts, if applicable

It is the provider’s responsibility to ask the beneficiary if they have OHI that is primary to TRICARE. The provider must also submit the claim to the primary payer before filing a claim with TRICARE. The claim will be denied if there is an indication of primary OHI and if the provider submitted the claim without other payer EOB or COB payment information. If TRICARE receives the claim before OHI processes it, the claim will be denied.