Tricare warning — The Bump
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Tricare warning

So as per my post last night, I have been having some issues with Tricare and my 20 weeks ultrasound. Well after speaking with Tricare again today and with my doctors office...both agreed that the 20 week anatomy scan is not "medically necessary" and therefore Tricare Prime does NOT cover it. Apparently my doctor can submit a letter to Tricare to try and get them to cover it but just a heads up to anyone who is Prime but does not go to a MTF, be careful with this u/s. They want me to pay $400 for this u/s.

Re: Tricare warning

  • NSLNSL member
    This is not normal Tricare policy.  Appeal.
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  • I don't even know where to start. I have spoken with multiple people from Tricare and they all say the same thing. In fact, today, the woman that I spoke with cut me off mid sentence and simply asked, "is there anything else I could help you with...?" and ended the call. I am just beyond frustrated. I am going to see what happens with my doctor and this "letter" and I will have to go from there. I have never heard of maternity care that did not involve the 20 week ultrasound. But I guess, according to Tricare, it is unusual to have them. Nothing like adding stress and putting a damper on the rest of my final pregnancy.
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  • That's not true. Even the Tricare website used to state that it was covered, though I don't know if it still says it or not. Whoever gave you that information is not correct. I had several ultrasounds with my son, and I never once got charged a dime.
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  • That seems really weird.  Just did some research - tricare prime covers maternity ultrasounds for the following reasons (C&Ped from their website, sorry if the formatting comes out weird when it posts):

    • Estimating gestational age
    • Evaluating fetal growth
    • Conducting a biophysical evaluation for fetal well-being
    • Evaluating a suspected ectopic pregnancy
    • Defining the cause of vaginal bleeding
    • Diagnosing or evaluating multiple gestations
    • Confirming cardiac activity
    • Evaluating maternal pelvic masses or uterine abnormalities
    • Evaluating suspected hydatidiform mole
    • Evaluating the fetus's condition in late registrants for prenatal care

    TRICARE does not cover maternity ultrasounds for routine screening or to determine the sex of the baby.

    I'm wondering if the folks you're talking to are thinking that this 20 week scan is for the purpose of determining the sex.  In truth, that's a bonus, but the scan is really for the purpose of evaluating the baby's growth and verify that it is completely normal, therefore it SHOULD be covered.  I say, get off the phone and go to your local Tricare office.  Take in as much info as possible about what an anatomy scan is for and what Tricare already says they cover.  Talk to a real person and get some real answers.  And if they still say no, find out the appropriate channels for appeal. 

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  • What really confuses me about this decision of theirs is that all the women I know who were on Prime at an MTF got 20 wk u/s standard no questions asked (as did those of us on Standard off post). Are they just fighting it for the fun of it bc you see an off-post Dr on Prime???

    I am not a fan of how convoluted Tricare can be and how their enforcement of guidelines can vary person to person for no apparent reason. Sorry for your frustration! :

  • I have Tricare Prime, see a doctor off post and my 20 week ultrasound was covered with no issues.
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  • Ditto everyone else about appealing. I was on Prime until 2 weeks ago, and they covered 4 ultrasounds: 10 weeks, 20 weeks, 27 weeks, 33 weeks. 
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  • OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

  • imageBrintardo:

    OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

    Tricare standard DOES cover 20wk U/S.  I was on standard and never paid a penny for anything.

    The 20wk U/S IS medically neccesary as it determines how your baby is growing and if there are any problems.  It is NOT to determine the sex which they do NOT cover.

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  • imageBrintardo:

    OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

    I have Standard and my 20w u/s was covered. I had 2 u/s before 20w and both of those were covered also.

  • Both Prime and Standard cover the anatomy u/s because it is considered medically necessary to check the baby's growth.  Call your doctor's office and see if maybe they coded it wrong.  Keep appealing until you talk to someone reasonable.  I've never heard of the anatomy scan being denied before, and that makes me wonder if maybe it's a coding error.  Good luck!

    And you don't even want to know how many u/s's I had (and even if you do I couldn't tell you because I stopped counting somewhere around 26 weeks).  I didn't have to pay a dime for any of them, except the 3D u/s I elected to have at one of those special places so that DH could have an u/s video to see because he was in Iraq. 

  • With my first baby (who's now 3.5), I was seeing an OB in town becuase our base didn't have OB care and I was on prime.  I only had an ultrasound at 14 weeks for dating purposes and that was it. 
  • The Dr's office has to code the u/s to reflect a medical necessity, and not a "standard" or "routine" u/s. Talk with the billing manager of the clinic, show them the list of reasons that Tricare considers medically necessary, and see if they will change the coding of the u/s from the appointment.
  • imageGreen*Flamingo:
    The Dr's office has to code the u/s to reflect a medical necessity, and not a "standard" or "routine" u/s. Talk with the billing manager of the clinic, show them the list of reasons that Tricare considers medically necessary, and see if they will change the coding of the u/s from the appointment.

    This. It's a doc problem, not a Tricare problem.

  • I had the same problem with my first ultrasound at 8ish weeks.  After many phone calls to doctor's office and tricare, I had to just pay out of pocket.  I even had the dr office recode it and refile it with tricare and still had no success.  So far, my 20 week ultrasound has been covered, but now I'm wondering if that will come back to me as well?  Good luck.  I hope you have a better turnout than I did!
  • imageBrintardo:

    OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

    Tricare Standard DOES cover the 20 week us. I have Standard and all four of my ultrasounds were covered with no problem. The last two were due to complications, but the first two were the normal 1st one and then the anatomy scan. Standard did not have one bit of a problem covering it.

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  • imageMarinemommyof4:
    So as per my post last night, I have been having some issues with Tricare and my 20 weeks ultrasound. Well after speaking with Tricare again today and with my doctors office...both agreed that the 20 week anatomy scan is not "medically necessary" and therefore Tricare Prime does NOT cover it. Apparently my doctor can submit a letter to Tricare to try and get them to cover it but just a heads up to anyone who is Prime but does not go to a MTF, be careful with this u/s. They want me to pay $400 for this u/s.

    This is not a TRICARE issue, since TRICARE has always been clear on what it covers and an U/S around 20 weeks IS done for some medical issues (I am having difficulties opening TRICARE and certain American websites in Germany right now). 

    .

    Now, that a 20weekish U/S is considered Standard Medical Practice, which is why TRICARE does cover them, when coded properly.  My suggestion would be to go online to get some civilian resources that talk to the reasons behind a 20 week U/S (not just the TRICARE site), so you can quote it when you talk to your Provider. 

    All you need is to have the Doc office recode the bill and resubmit it.  HOWEVER, if you have had one U/S in the last couple weeks that WAS paid for, this may be why they are coding it differently.  You already had the medically necessary one.

    But either way, this is a PROVIDER ISSUE, not TRICARE ISSUE (this happens in the civilian world too).

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  • imageThe_Spanish_Inquisition:

    imageGreen*Flamingo:
    The Dr's office has to code the u/s to reflect a medical necessity, and not a "standard" or "routine" u/s. Talk with the billing manager of the clinic, show them the list of reasons that Tricare considers medically necessary, and see if they will change the coding of the u/s from the appointment.

    This. It's a doc problem, not a Tricare problem.

    Exactly. I had probably like 7-8 u/s all requested by the doc and all considered "medically necessary" since they wanted them done to check on various things. I am on standard and never got a bill for a single one.

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  • Tricare will refuse to pay anything billed as not medically necessary. I had the anatomy scan and several u/s and tricare paid. Everything billed to tricare needs to say it is medically necessary or else they will try to escape paying. If it says on their website they pay then hold them to their word. Definitely fight it!
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  • I'm on Tricare Standard as of Sept.  Before that I was on Prime and in Germany where they do u/s at every appt. and all of those were covered.  When I got home I switched to Standard and I had a anatomy scan which they DID NOT cover.  They said they WOULD have if I had "authorization" before hand but I never got it authorized by them so they wouldn't pay for it.  Blah.  Mine was only $100 though, I'm sorry you had to pay $400!
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  • Regardless of TriCare policy, I was told when I called TriCare that they weren't paying for my u/s because it wasn't medically necessary.  I even made sure to ask the woman very specifically: "Are you telling me that the 20 week u/s standard in most pregnancies is not covered?"  And she said "yes." 

    In summary, TriCare is an excellent service but it is severely disorganized--paperwork errors are rampant, and that's not just from my experience.  I'm not complaining--I had my baby without paying out of pocket for anything once the paperwork issue got cleared up, but it is something you have to watch out for.

  • Oh the joys of Tricare.

    I had a similar issue with them yesterday. I was sent off base for the NT scan because the person on base that does the more in-depth ultrasounds is deployed and so they were sending everyone off base. At the end of my appointment the Dr. told me that I needed to also make my 20 wk Anatomy scan with them because they would be doing it to. I called Tricare to make sure it would be covered for me to go off base for it also since I had already been referred to them.

    At first the woman said Yes, because I was approved for 2 visits. Then she said the office visit is the only thing covered no ultrasounds are covered. I tried so hard to get this thick headed idiot to understand that the Dr. I was referred to did not offer any other services than the NT scan, Anatomy scan and genetic screening. He does not do consults or other types of care. All she would do is repeat to me that the visit was covered and the ultrasound was not. 

     So I called the office back and asked them about it and the receptionist and Doctor both said that they run into this issue with every Tricare patient they have. That they have to explain to them every single time that all they do is ultrasounds so by approving me to be seen at his office in general they already approved the ultrasound. 

    Try talking with your doctor again, from my understanding all they have to do is code it as medically necessary and Tricare can not refuse to pay. 

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  • Yea see my big question is why the Tricare agents ALL say they do not cover the Anatomy Scan for 20wks for Prime at non MTFs but EVERYONE who goes to an MTF gets one no questions asked no bills at all...its standard...
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  • imagesimo7079:
    I'm on Tricare Standard as of Sept.  Before that I was on Prime and in Germany where they do u/s at every appt. and all of those were covered.  When I got home I switched to Standard and I had a anatomy scan which they DID NOT cover.  They said they WOULD have if I had "authorization" before hand but I never got it authorized by them so they wouldn't pay for it.  Blah.  Mine was only $100 though, I'm sorry you had to pay $400!

    Tricare Standard doesn't require prior authorizations.   Were you officially on Standard at the time of the ultrasound, or still considered Prime?  

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  • imagetheaustins05:
    Yea see my big question is why the Tricare agents ALL say they do not cover the Anatomy Scan for 20wks for Prime at non MTFs but EVERYONE who goes to an MTF gets one no questions asked no bills at all...its standard...

    I was on Prime for my first pregnancy, but my OB was a civilian out in town.  My anatomy scan, NT scan, plus about 5-6 others were all covered. 

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  • imagebootsie08:

    imagesimo7079:
    I'm on Tricare Standard as of Sept.  Before that I was on Prime and in Germany where they do u/s at every appt. and all of those were covered.  When I got home I switched to Standard and I had a anatomy scan which they DID NOT cover.  They said they WOULD have if I had "authorization" before hand but I never got it authorized by them so they wouldn't pay for it.  Blah.  Mine was only $100 though, I'm sorry you had to pay $400!

    Tricare Standard doesn't require prior authorizations.   Were you officially on Standard at the time of the ultrasound, or still considered Prime?  

    Nope I was on Standard.  I mean I didn't feel like arguing w/ them it was only $100, but I thought it just stupid.   

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  • imageErin2903:
    I have Tricare Prime, see a doctor off post and my 20 week ultrasound was covered with no issues.

    ditto!

  • imagetheaustins05:
    Yea see my big question is why the Tricare agents ALL say they do not cover the Anatomy Scan for 20wks for Prime at non MTFs but EVERYONE who goes to an MTF gets one no questions asked no bills at all...its standard...

    The providers code the u/s as medically necessary at the MTFs.

  • imageBrintardo:

    OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

    This is not true for all. I had TriCare Standard with my daughter and the 20 week u/s WAS covered with no questions asked. We paid nothing and found out the sex of our baby.

  • imagetheaustins05:
    Yea see my big question is why the Tricare agents ALL say they do not cover the Anatomy Scan for 20wks for Prime at non MTFs but EVERYONE who goes to an MTF gets one no questions asked no bills at all...its standard...

    Ok, I am not and have not been pregnant. But my understanding regarding this issue is they dont cover an ANATOMY scan. They cover 20 week scans for growth/whatever. But not to soley chack the gender. SO I am betting, like PPs said, this is most likely a coding issue.

    If the only reason you went in for a check was to see if you have a boy or girl, unnecessary. If the scan showed you that, but was done for other purposes that have need, its covered. This is not unique to Tricare.

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  • Okay I work for a radiology clinic so I'll try to explain this best I can. Our radiology is hospital based but the AFB by us doesn't have a hospital so they send their patients out.

    You are authorized by Tricare and U/S that is medically neccessary.

     Typically the 1st u/s is a dating u/s to estimate the gestational age and give you an EDD. At that time a radiologist can not speak on terms of fetal development.

     At a later date (typically 20 weeks) they due the anatomy scan to look at all the organs, the placenta, etc.

     Beyond that tricare can deny claims and if another medical neccesity arises God forbid it must be coded as such and often with Tricare require pre-authorization.

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  • I have Tricare standard and BCBS from my work.  I have been told numerous times that neither insurance will cover my 20 week ultrasound.  But I have also been told by the same people who told me that it wouldn't be covered not to pay anything till after I have the baby.  So I'm still waiting to find out if either insurance company will pay for it. 
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  • Yep, we have Tricare Prime and I had to pay for my ultrasound. $528. There was no way I was going to agree to no ultrasound. I wanted to be sure my baby was okay. It is absolute bull crap that Tricare doesn't pay for them unless you're high risk. We're military families for God's sake. We aren't made of money! Our ultrasounds should be paid for.

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  • Oh FFS. Let me explain this out-

    When your MW/OB/whoever does your u/s, when they chart they assign a little code number to the procedure so that the procedure can be billed appropriately. If they pick one of the codes that Tricare deems "medically necessary", then the u/s is paid for in full by Tricare. If the provider puts down any other code at all, other than those approved by Tricare, then when the u/s is billed Tricare will not pay for it.

    The term "standard" is confusing some people. Just because everyone and their dog gets a u/s around 20 weeks does not mean in the medical coding world that it is a standard u/s. Those 20 week u/s are being coded as being medically necessary, which is why they are paid for. If yours was not paid for, you should contact the billing department at the clinic/hospital and have the code changed and the bill resubmitted.

    Tricare states over the phone and on their website that they do not cover "standard" u/s....because they don't. They cover medically necessary ones.

    Does this make sense? Proper code+ u/s= paid for, not proper code +u/s= not paid for. It has absolutely nothing to do with on post, off post, etc.

  • imagekelslynie:

    Yep, we have Tricare Prime and I had to pay for my ultrasound. $528. There was no way I was going to agree to no ultrasound. I wanted to be sure my baby was okay. It is absolute bull crap that Tricare doesn't pay for them unless you're high risk. We're military families for God's sake. We aren't made of money! Our ultrasounds should be paid for.

    Not true. Low risk women have them all the time, it is up to the doc/clinic to code appropriately for billing. If your provider chooses not to perform more u/s because you are low risk, that is something you can take up with your provider. It's not a Tricare issue.

  • imageeuno:
    imageBrintardo:

    OK.  The same exact thing happened to me.  I THOUGHT I had been enrolled in TriCare Prime, but after having the u/s I was told that there had been a paperwork error (surprise!) and I was in fact enrolled in standard, which does NOT cover a 20 week u/s.  

    Luckily for me, the billing department of my Dr.'s office said it was a procedure that they couldn't bill me personally for and the whole thing magically disappeared. 

     

    This is not true for all. I had TriCare Standard with my daughter and the 20 week u/s WAS covered with no questions asked. We paid nothing and found out the sex of our baby.

    I'm glad you didn't have any problems, but that doesn't mean my experience is made up.  It absolutely IS what happened.  Thanks though. 

  • I know this is going to sound like scamming the system, but go to the emergency room with cramps, nausea, dehydration, dizziness, etc.  If you are pregnant and go to the ER you will automatically get an ultrasound.  Screw Tricare, if they won't pay for a normal ultrasound then they can pick up the tab for an ER visit. 

    Also, there's a lot of places that do 3D ultrasounds for around $100 and are great at giving military discounts.  You still have to pay, but it's amazing how great customer service is when you go to a business that needs paying customers.

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  • I didnt have a problem when them at all... complain.. it usually works. good luck!

     

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