Tricare and You – Denied Procedures
Posted by PA2 Connie Terrell, Monday, February 27, 2017
This blog is the most recent in a series helping members of the Coast Guard family understand how to use their TRICARE benefits. The blog series will continue every Monday, right here on Coast Guard All Hands.
Written by Cmdr. Paul Fawcett, chief of Medical Administration for Coast Guard’s Office of Health, Safety and Work-Life
There are certain clinical procedures that TRICARE is prohibited from approving, even if a valid referral is submitted by your provider. In some cases you may see that a series of procedures has been submitted and TRICARE issued you a letter approving some and denying one or more. TRICARE publishes a list called the No Government Pay Procedure Code List, often called the No Pay List. If your procedure is on that list, it will be denied for payment by TRICARE.
The No Pay List
If you’re reading the list the first thing you will notice is that procedures are listed by code and not name. Usually when you get your letter from TRICARE stating what is and isn’t approved the code will be included so you won’t have to look it up, you can just compare the code that was denied against the No Pay List to see that it’s there. If you don’t have the code you can use one of the internet search engines to research the Current Procedural Terminology (CPT) code, a medical code set and maintained by the American Medical Association, for your procedure. The No Pay List will tell you why a particular procedure is not allowed. These reasons may include:
(X) Excluded by policy or statute
(U) Unproven or experimental
(D) Code deleted
(NR) Code not recognized under TRICARE
What are your options?
“Can’t I just have the procedure anyway?”
Well that depends. If you are a civilian, yes. However, TRICARE just told you they wouldn’t pay for it, so if you do have it, you could be left with a bill to pay. If you are active duty, you cannot have a procedure denied by TRICARE as it may be contrary to law or policy.
“Can I appeal?”
Yes, you can. There are several types of appeals. TRICARE has instructions and forms that you can use to file your appeal. Appeals take time and may not be resolved in your favor, so don’t schedule your procedure with a short suspense date and hope your appeal is resolved quickly in your favor – it may not be. Only civilians should appeal, military should follow other courses of action listed below.
“But I’m a uniformed service member and my doctor says I need this procedure.”
There are some options. You may be able to have your medically necessary procedure completed at a Military Treatment Facility, even though TRICARE would not pay for it on the network. Your military doctor will have to help you through that process. If you have a civilian network provider, you will need to be connected with a Coast Guard provider at your nearest clinic for this option.
Supplemental Healthcare Waivers
If you are a Coast Guard active duty member and received a letter from TRICARE denying your procedure it probably came with a “call this number” statement. That number starts the supplemental healthcare waiver process. A waiver request is the service asking the Defense Health Agency (DHA), which is the government agency overseeing TRICARE, that this procedure is needed anyway and would they please approve it.
Waiver requests start with a Coast Guard provider reviewing the procedure and sending a request to the Health, Safety, and Work-life Service Center for review. It ends at DHA with a flag officer signature. As you can imagine, it’s a lengthy process. While waivers do get approved, they aren’t fast and can’t be expedited. Procedures that are prohibited by law for active duty members will not be approved.
You should be aware that certain elective and cosmetic procedures are not a covered benefit under TRICARE. In those cases, appeals and waivers would not be successful. Appeals and waivers are designed for medically necessary procedures. If you have questions about your benefit and what’s covered you can visit the TRICARE Website to learn more.