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
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):
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.
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! :
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.
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.
This. It's a doc problem, not a Tricare problem.
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.
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).
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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).
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.
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.
Tricare Standard doesn't require prior authorizations. Were you officially on Standard at the time of the ultrasound, or still considered Prime?
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.
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.
ditto!
The providers code the u/s as medically necessary at the MTFs.
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.
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.
I changed my name
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.
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.
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.
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.
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.