Understanding your TRICARE explanation of benefits

  • Published
WHITEMAN AIR FORCE BASE, Mo. --  Many people misread or misunderstand the information in their
explanation of benefits. Understanding how to read your EOB can
help you manage your TRICARE benefits better and can help you save
money.

Fast Facts about your EOB

After each visit to a medical provider, you are sent an EOB from
TriWest. Your EOB is not a bill. It is a summary that outlines how your
TRICARE benefits were applied to the charges billed by your doctor. If
you have additional cost-shares, you will receive a bill from your
doctor after your claim has been processed.

EOBs are sent to the patient (or parent or guardian for minors) at the
address noted on the claim. If you have recently moved, you should
update your address with your doctor's office, TriWest and DEERS to
ensure the correct address is included on your claim form (if your
doctor is billing TRICARE on your behalf) and that you receive your EOB
and other medical information at your current address.

Reading your EOB

Explanation of benefits

1. Mail-to name and address - We mail the TRICARE EOB directly to
the patient (or parent or guardian) at the address noted on the claim,
be sure your doctor has updated your records with your current address.
2. Date of Notice - The date your TRICARE EOB was prepared.
3. Sponsor SSN/sponsor name - we process your claim using the
social security number of the military service member (active duty,
retired or deceased) who is your TRICARE sponsor.
4. Patient name - the patient who received medical care and for
whom this claim was filed.
5. Claim number - TriWest assigns each claim a unique number. This
helps us keep track of the claim as it is processed and allows us to
locate the claim quickly when you call or write us with questions or
concerns.
6. Check number - a check number will appear here only if a check
accompanies your EOB.
7. Toll-Free number/Web address - how you can reach us at TriWest
if you have questions.
8. Service provided by - the health care provider (doctor,
hospital, lab, etc.) that provides your medical care, the number and
type of services you received and the procedure codes.
9. Date of services - the date you received the care.
10. Amount billed - your health care provider charged this fee for
the medical services you received.
11. TRICARE allowed - the monetary amount TRICARE approves for the
services you received.
12. Remarks - If you see a code or a number here, look at the remark
codes section (16) for more information about your claim.
13. Claim summary - a detailed explanation of the action taken on
your claim. You will find the following totals: amount billed; amount
approved by TRICARE; non-covered amount; amount that you have already
paid to the provider, if any; amount your primary health insurance paid
(if TRICARE is your secondary insurance); benefits paid to the provider;
benefits paid to the beneficiary.
14. Beneficiary share - you may be responsible for a portion of the
fee your doctor has charged. If so, you'll see that amount itemized
here. It will include any charges that we have applied to your annual
deductible or any cost-share or co-payment you must pay. You will
receive a separate bill if you are responsible for any charges.
15. Out of pocket expenses - displays the portion of the annual
individual and family deductible and maximum out-of-pocket expense you
have met to date. We calculate your annual deductible and maximum
out-of-pocket expense by fiscal year. See the fiscal year beginning date
in this section for the first date of the fiscal year.
16. Remark codes - explanations of the codes or numbers listed in
remarks (12) will appear here.
17. Paid to - the provider or facility to which the claim was paid.
18. Regional contractor - the name "TriWest Healthcare Alliance" and
the TriWest logo will appear here.

(Information courtesy of 509th Medical Group)