Community› The Bump Message Boards› Military Families
Military Families
New Discussion

Question about Tricare Prime...backdating referral? Please help?

Salamander87Salamander87
in Military Families

Hi Ladies.  A lot of you are much more knowledgeable than me when it comes to Tricare.  

Little back story, I  was on Tricare Standard up until December.  My DH then had me switched to Prime. Well, at my last OB appt, I noticed that they had STD written on the bottom of the paper?  I asked if that meant Standard ( and not a sexually transmitted disease they just happened to keep from me :/).  She said yes, and I told her my husband had switched me to Prime earlier in the year, and they had been told.  Well, I got a call from my OB's office yesterday saying I need a backdated referral from my PCM to cover my visits up to this point.  I have an appointment with my PCM on Monday morning, and a visit with my OB on Monday afternoon.   Is it normal practice to backdate referrals?  If not, am I going to have to pay completely OOP for my visits so far?  Thanks so much in advance for any help you can give me ladies!

Pregnancy Ticker BabyName Ticker image
Report Reply to Post

Re: Question about Tricare Prime...backdating referral? Please help?

  • F15WifeF15Wife member
    It is totally normal to backdate. You need to call your PCM and let them know what happened. They can backdate the referral for you and no you will not have to pay for you visits thus far. You  may have to call tricare yourself and let them know the story and also let them know the referrals have been backdated and THEN after all is set and done let the OB know to bill again.
    Baby Birthday Ticker Ticker Baby Birthday Ticker Ticker Baby Birthday Ticker Ticker
    Report Reply
  • Loading the player...
  • Salamander87Salamander87
    Thank you so much.  You really don't know how much stress you lifted off of me.  :)
    Pregnancy Ticker BabyName Ticker image
    Report Reply
  • Temp76535187505890Temp76535187505890
    Regardless of Prime vs Standard and when the switch occurred, all of your pregnancy related visits should be covered provided your OB bills to Tricare. There shouldn't be any out of pocket expenses as long as everything is coded and submitted correctly....for pregnancy related visits only. 
    Report Reply
  • Salamander87Salamander87
    The insurance biller at the office said I would have to pay out of pocket if my PCM didn't backdate my referral.  That's why I was kind of freaking out...not the news I wanted to hear at 38 weeks pregnant.   But even if they didn't backdate to January, couldn't I switch back to Standard and have my OB's office backdate?  Since maternity is completely covered?  I am just really ignorant when it comes to Tricare.
    Pregnancy Ticker BabyName Ticker image
    Report Reply
  • Lissa832Lissa832 member

    You are 38 weeks pregnant. Why was this not handled months ago? Your doctor has been billing Tricare, so they had to know something was wrong. If the referral isn't submitted, you can be responsible for 50% as POS, I believe. For example, if you are Prime but don't want to be seen on base, then you can choose this option and pay half OOP.

    The real question here is whether or not there is a MTF nearby that services OB patients. If the is, then you might be in trouble because your PCM can issue a referral to your OB, but Tricare would reroute you to the MTF if they offer OB care. The bottom line is that if there is a MTF in the area that you would normally be seen at, then I would expect to pay something OOP. If there is not, then you shouldn't have an issue getting this straightened out.

    This was your responsibility. I just don't get why so many people have so many issues understanding Tricare. It is rather simple. Prime=referrals BEFORE care. Standard=no referrals but pay cost shares/deductible.

    Lilypie Kids Birthday tickers Lilypie First Birthday tickers
    Report Reply
  • Salamander87Salamander87
    We told my ob's office about it when we first switched to Prime.  I was already seeing the same OB before then for Prenatal care, and no one said anything about having a referral since I was already seeing them.  I know that it is my fault for assuming.  My PCM is off base, because we live far enough away.  I know that my OB is in network and accepts Tricare Standard and Prime.  I know this should have been handled, and am looking to get it straightened out next week when I see my PCM.
    Pregnancy Ticker BabyName Ticker image
    Report Reply
  • Lissa832Lissa832 member

    imageSalamander87:
    We told my ob's office about it when we first switched to Prime.  I was already seeing the same OB before then for Prenatal care, and no one said anything about having a referral since I was already seeing them.  I know that it is my fault for assuming.  My PCM is off base, because we live far enough away.  I know that my OB is in network and accepts Tricare Standard and Prime.  I know this should have been handled, and am looking to get it straightened out next week when I see my PCM.

    If you would have been referred out to a civilian anyway, then you shouldn't really have an issue. Did you not know that you needed a referral with Prime? Your OB sounds like he/she is acquainted with Tricare. Most providers ask right away, Prime or Standard when you call for an appointment. When you say Prime, they tell you to get a referral and will not set up an appointment until after they get confirmation from Tricare. I would ask them at the next appointment if they've received payment from Tricare. Have you received any EOBs from Tricare that shows your responsibility? If not, then it might already be taken care of. When I was Prime, I never received an EOB? When I switched, it seems like I get them every other week.

    Lilypie Kids Birthday tickers Lilypie First Birthday tickers
    Report Reply
  • Salamander87Salamander87
    I was already seeing my OB when my husband had me switched in January, so that have been when they hadn't asked.   I haven't received anything from Tricare at all.  I did receive a bill from my OB in December and a bill for some labs, but nothing since I have switched to Prime.  
    Pregnancy Ticker BabyName Ticker image
    Report Reply
This discussion has been closed.
Choose Another Board
Search Boards
"
"