Patient Administration - Army Publishing Directorate - U.S. Army

13–7. Concurrent medical affirmative claims and Third Party Collection Program health insurance
claims
a. A beneficiary may be covered by both health benefits insurance and another type of insurance, such as
automobile. Consequently, there would be more than one insurer. However, the Government cannot collect more than
the cost of medical care from any one source or combination of sources.
b. MTFs and RJAs will establish procedures to facilitate the exchange of information regarding claims and ensure
coordination between the MTF and the RJA regarding any concurrent TPCP health insurance claim(s) and subsequent
payment(s).
(1) When a beneficiary is covered by both a TPCP health benefits insurance claim and a medical affirmative claim,
the MTF will simultaneously—
(a) File the MTFs TPCP health benefits insurance claim;
(b) Notify the RJA of the MTFs concurrent TPCP health insurance claim; and
(c) Provide the RJA with information regarding the potential or ongoing medical affirmative claim.
(2) Initial notification to the RJA regarding a potential medical affirmative claim cannot be postponed until payment
has been received from the TPCP insurer. The RJA must be notified promptly of treatment for an illness or injury due
to a potentially recoverable incident in order for the RJA to proceed with the investigation of the incident and meet
assertion and notification deadlines.
(3) When the beneficiary is covered by worker’s compensation (non-Federal employer) for a job-related injury or
illness, the MTF does not file a claim with the patient’s health benefits insurer. On-the-job injury claims are filed by
the RJA as a medical affirmative claim. They are not a TPCP health insurance claim. (See appropriate regulations
regarding on-the-job injury claims for Federal employees.)
(4) MTFs will, upon receipt, provide pertinent information regarding health insurance payment(s) or denials on
concurrent medical affirmative claims to the RJA. This information will include relevant patient and spousal information,
dates of treatment, name of health insurer, the amount claimed, and the amount of payment(s); or, the denial date
and reason for denial. A copy of the TPCP claim form(s), the insurance explanation of benefits form(s), or denial will
be provided to the RJA on request. The RJA will adjust the asserted amount of the medical affirmative claim
accordingly. A copy of the transmittals to the RJA regarding concurrent TPCP health insurance claims will be
maintained with the TPCP claim as part of the file.
13–8. Civilian care furnished Family members and retirees in the United States, Puerto Rico, Canada,
and Mexico
The Director, TRICARE Support Office, has responsibility for issuing directives regarding procedures to be followed
by civilian MTFs and fiscal intermediaries when Family members or retirees receive initial care and treatment,
necessitated by a traumatic injury, at civilian facilities as TRICARE beneficiaries. These directives require that—
a. Notification is made to the RJA or other legal official according to AR 27-20.
b. Invoices, statements of account, statement of causative factors, and other available information specifically
requested by the individual mentioned in a above, are furnished.
c. The DD Form 2527 (Statement of Personal Injury—Possible Third Party Liability TRICARE Management
Activity) is completed, according to instructions on the form, by the injured party, sponsor, or other responsible Family
member as soon as possible after the patient’s treatment by a civilian provider/practitioner.
d. A copy of the completed DD Form 2527 is furnished to the appropriate RJA as soon as possible so that he or she
may advise the injured party according to AR 27-20.
13–9. Civilian care furnished Family members and retirees in the European command
When payment is made for civilian inpatient care and it appears that the care was necessitated by a traumatic injury,
the Executive Director, TRICARE Support Office, Europe, will furnish the information required in paragraph 13-8 to
the appropriate Service commander.
13–10. Civilian care furnished Family members and retirees in areas other than the United States,
Puerto Rico, Canada, Mexico, and in the European command
Approving authorities (DOD 6010.8-R), who process payments to sources of civilian health services or claims for
reimbursement for civilian inpatient care obtained by TRICARE beneficiaries, will forward a copy of the approved SF
1034 and 1034A to the RJA in all injury cases where the patient was hospitalized or obtained emergent or urgent care.
13–11. Claims for reimbursement for civilian care
Instructions relevant to claims for reimbursement for civilian care can be found at the TRICARE/DOD Health Affairs
Web site (http://www.tricare.osd.mil/).
13–12. Care in medical treatment facilities of a foreign government
The notification procedures required in paragraphs 13-8 through 13-11, as applicable, will be followed when payments
AR 40–400 27 January 2010
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