Claims Go to TRICARE or VA (not both)

Wednesday, June 14, 2023
Reprinted with permission from the Defense Health Agency, Communications Division

Some TRICARE enrollees are eligible for health care benefits not only through the Department of Defense TRICARE program, but also through the Department of Veterans Affairs (VA) Community Care program. For these dual-eligible beneficiaries, you can file a claim with only one federal agency for payment, either TRICARE or VA, but not to both.

If you file a claim to both TRICARE and VA for the same services, it could lead to double payments. It could appear that you are intentionally seeking double/duplicate payments from the federal government. That could result in recoupment actions, administrative fees, penalties, and fines, as well as the possibility of federal provider exclusion, suspension, or termination.  

Claims for non-emergency care
All non-emergency VA Community Care requires a VA referral for authorization. While dual eligible beneficiaries might be covered by one of several TRICARE health plans, only TRICARE Prime requires referrals for most services. See the decision tree below.  

When sending non-emergency claims to TRICARE or VA, remember the following:

• File claims with only one agency, not both. Providers must obtain the appropriate agency referral as required and file claims with the correct agency for payment.
• Dual-eligible beneficiaries using their VA benefit must have a VA referral for provider payment. 
• If TRICARE referred, submit only to TRICARE.   
• If VA referred, submit only to VA. 
• If unsure, and there is no referral, ask the dual-eligible beneficiary, “Would you like to use your VA or your TRICARE benefit?” 

Claims for emergency care
If you provided emergency care, a referral is not required, but please remember the following: 

• Ask the beneficiary to choose VA or TRICARE for claims payment purposes (if they are eligible for both).  
• If VA authorizes the care, then properly file the claims with the VA.  
• If the beneficiary chooses to use TRICARE, then file the claims with TRICARE.
• If the dual eligible TRICARE sponsor is not able to respond, you must contact VA within 72 hours using  https://EmergencyCareReporting.CommunityCare.va.gov, or by calling 844 72HR-VHA (844-724-7842) to authorize the care provided if VA benefit is expected to be utilized by the beneficiary. This VA hotline is available 24 hours a day.  

Decision tree

Figure 1. Decision Tree for VA /TRICARE Dual-Eligible Veterans

TRICARE referral and authorization rules
In general, TRICARE Prime requires referrals for non-emergency care in the private sector. When a dual-eligible TRICARE Prime enrollee is referred to a TRICARE provider for care, Humana Military or Health Net Federal Services is noted as the authorizing agency on the authorization for care. You file claims for those services in accordance with applicable TRICARE requirements.

TRICARE Select does not require referrals for most care. If a dual-eligible TRICARE Select enrollee does not have an authorization for care from VA, submit your claim to TRICARE. When a dual-eligible beneficiary chooses to use TRICARE benefits or if the VA is unable to authorize care, the provider should follow TRICARE authorization and claims processing instructions.