Military Families

Tricare doesn't cover any ultrasounds

Thought that might get you in here! :)

 

DD's birth was at an MTF (Womack at Bragg - very nice facility!), and we saw the midwife clinic there all through. We had the 20w ultrasound and that's it. Totally fine with that policy.

 

I'm 12w along with #2 and stationed >50 miles away from the nearest MTF, so we're on Tricare Prime Remote (basically same as Prime w/ no copays, and don't have to use an MTF). I went to my first appt with an OB yesterday and they wanted to do an ultrasound. I told them my ins. does not cover 1st tri and they kinda freaked out and said "how can we confirm the pregnancy without an u/s?" "Uhh, with a blood test and external exam?" (helloooo, 2nd time around, I'm clearly showing uterine swell!)

 

So DH and I, separately, call Tricare to inquire and are both told that they cover zero ultrasounds. Without medical necessity. Said that if we got one with #1, it was because the MTF gave them, not because of Tricare.

And so it is:

https://www.hnfs.net/common/benefits/ultrasound_policy_040106.htm

 

I haven't told my friends IRL who had kids with private providers, and I'd like to ask them, but I guess they all got their providers to submit medical codes of "poor fundal height growth" and other fake diagnoses to get their u/s? Sheesh.

 

 

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Re: Tricare doesn't cover any ultrasounds

  • Tricare doesn't cover anything without medical necessity. It may be for dating purposes, but that is considered a medical necessity by many providers when an EDD cannot be exactly determined with other means.

    Tricare will cover the u/s, the office has to code it correctly so that it is covered.

  • I saw a private provider on Tricare Standard (closest base was about 100 miles away - DH was deployed so I moved back from Germany for my pregnancy) and had the 20 week anatomy scan as well as follow up ultrasounds that were medically necessary (placenta previa) and was never billed for any of them.  I don't believe that my doc coded the 20 week ultrasound under a fake diagnosis.  It was 2 years ago so I suppose things could have changed. 

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  • I had several U/S's with DD and 3 with this pregnancy so far.  None were "fake" diagnoses.  Dating ultrasounds, anatomy scan, etc. ARE considered medically necessary.  "Medically necessary" does not = problem or emergency. 
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  • I had 4 with DS and they were all covered; a dating because he was conceived on b/c and we didn't have a clue when, an "viability" scan because doc couldn't find a HB at my 15 wk appointment, the standard anatomy scan, and a growth US in 3rd tri because I was exhibiting signs of PIH. There are a variety of reasons why US may be needed just be sure to check with your doctor to ensure they are being coded correctly.
  • I had the same problem actually.  I was in Germany when I first found out I was pregnant and the base we were at sends you to a local OB/GYN and there you get ultrasounds at every appt and we never had a problem.  Then I came home b/c my hubby is getting medically discharged, and I had to go from Prime to Standard b/c I'm not near a base.  Anyway I had an ultrasound to check her organs and what not, then I got the bill a couple weeks ago.  I called Tricare and they said they cover that kind of ultrasound HOWEVER I didn't get it approved first.  I mean really?  Once you aren't on a base, or near a base I feel like they just give up on taking care of you.  Blah.
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  • image simo7079:
    I had the same problem actually.  I was in Germany when I first found out I was pregnant and the base we were at sends you to a local OB/GYN and there you get ultrasounds at every appt and we never had a problem.  Then I came home b/c my hubby is getting medically discharged, and I had to go from Prime to Standard b/c I'm not near a base.  Anyway I had an ultrasound to check her organs and what not, then I got the bill a couple weeks ago.  I called Tricare and they said they cover that kind of ultrasound HOWEVER I didn't get it approved first.  I mean really?  Once you aren't on a base, or near a base I feel like they just give up on taking care of you.  Blah.

    I'm on Standard and I've never had to get an ultrasound approved.  Standard does not require prior authorization.  Is your doctor a Tricare Network provider?  If so, I would definitely dispute this.  The doctor should have filed the "global maternity" paperwork. 

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  • A dating ultasound is considered a medical necessity and would absolutey be covered.
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  • TRICARE follows the Standard of Practice that most Civilian HMOs follow.  They will cover the initial dating U/S and then one at the 20 week mark to check on the overall health of the baby.

    Depending on how YOU and YOUR DH asked your questions, the TRICARE person would tell you no U/S if they were not medically necessary.  Which is true.  The two mentioned ARE medically necessary.

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  • From my understanding, "without medical necessity" is usually considered the situation where parents want to go back and have a second anatomy scan solely to find out the sex of the baby. A dating scan would be medically necessary to make sure dates are correct and set the standard for the baby's growth. They use the measurements from the dating scan to check the baby's growth is at least 10% at the anatomy scan.
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  • I am on Tricare prime but am seeing a civilian OB/GYN since we live far enough off base.  I have had 3 u/s with this pregnancy and had a few with my m/c in February and never once saw a bill.  Like the PP's have stated, a dating u/s is considered medically necessary.  Most Dr's offices won't perform an u/s unless they know it will be covered by your insurance.  At least I know mine would never do that.  My OB even found a way to get me an extra ultrasound when my husband got home since he had missed the first one.  Not sure how they coded it but I didn't have to pay for it.  
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  • I had 2 ultrasounds, the dating one early on and gender/development one at 20 weeks.  My friend who just had her baby last week probably had 7 or 8 ultrasounds because they couldn't figure out her dates.  Neither of us was charged because in each case we got what was medically necessary.
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  • I am currently 23 weeks pregnant and have had 3 ultrasounds.  As PP's mention the first one was 12 weeks and is considered a dating ultrasound, and they also check measurements to make sure everything looks ok with the baby.  They did not lie on the paperwork to get it covered, it is standard practice and considered medically necessary.  My 2nd was at 22 weeks and it was the anatomy scan, again my doctor did not lie to have this covered, it is standard practice and they also do measurements to make sure everything is still ok with the babies development.
  • I have Tricare Prime Remote and they covered every ultrasound I ever had. I didn't pay a dime for anything throughout my whole pregnancy and delivery.

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  • An ultrasound would also confirm that the pregnancy is where it should be ( not etopic ect.) So I see that being medicaly neccessary
  • Yeah I ran into the same problem initially.  Tricare billed me for my first US because of improper coding.  I called my Ob office and asked them to make sure that they code things properly so that insurance would cover it.  Tricare will cover anything as long as it's deemed medically necessary.  Once I called Tricare, they sorted everything out and paid for the first US.  Call me crazy, but I figured the first US to determine a viable pregnancy and heartbeat was medically necessary.  You gotta get a good person on the phone with Tricare as well who knows what the heck is going on.  Some of them are so clueless!  Good luck with Tricare. 
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