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Thread: Tricare prime....delivering baby in non-network hospital...anybody?

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    #1

    Tricare prime....delivering baby in non-network hospital...anybody?

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    So my complicated story is that we are supposed to be getting orders last minute back to the states from Germany (*fingers crossed*). I'm 31 weeks pregnant right now and have about 4 weeks left to fly home. Basically since we are still waiting on the orders, there's no way in hell our HHG will arrive in time for us to be settled at our next duty station. We are hoping to pcs to a base that is a 5 hour drive from home. In the meantime, we decided at this point it's best for me to have my baby while at 'home' (where our parents are from). I determined that I can be in tricare prime (it's the NYC area). In the network there are a number of primary care doctors to choose from, then I get a referral to an OB/GYN...there's only one good option in my area....The others are in Newark...which is not exactly the safest place to be visiting frequently. So the doctor I would prefer delivers at a hospital that is not 'in network'. My mom and I have made many phone calls to see what the best way to go about this but we just keep getting different answers. I'm looking for personal experiences... Ideally I would not want to be going to a hospital with an unfamiliar doctor. Not to mention most of the in-network hospitals are again not in the nicest of locations. It would make most sense to me to go to the hospital that my doctor delivers at! It is also a nicer hospital and within a reasonable driving distance from home. The hospital says they will accept tricare...when I search them, specific doctors come up as covered, but not the hospital itself as a whole. If I use that hospital with a referral, it should be covered right? I'm seeing that there's a point of service option...but every time I call tricare they say with a referral it would NOT fall under 'point of service' but they can still charge me. It almost seems 'safer' to go without the referral as far as costs go. but i'm just so confused! Worst case scenario is I go to a strange hospital and just deal with it, best case scenario is we get in writing from the 'out of network' hospital that they will accept tricare charges. SOOOo point being, anyone deliver in an out of network hospital and what was your 'tricare experience'? I know it can differ, just looking for what people have dealt with in the past.
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    I have standard but used a out-of-network birth center. I am not entirely sure how it worked, they billed them directly and tricare covered everything minus my deductible. I used the out of network provider search function which had the center on their list. I think it just means they have a billing relationship. Not sure if prime would work the same way though.
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    If you are on prime and go to a location that is not authorized then you will get billed and Tricare will not pay. Generally, when a hospital or doctor says they take Tricare it is usually Standard, not prime. Prime has to be seen at an MTF, and if that MTF is more than 50 miles you can use Prime Remote, but you have to call Tricare in advance.

    So, if your parents are not near an MTF, or they are more than 50 miles from the nearest MTF, then you can go on Prime Remote and you would have the same options as Tricare Standard. And its 50 miles as the crow flies, point A to point B.. regardless if it takes more than 50 miles to drive there.

    If the place in Newark is less than 50 miles, then you will likely be stuck going there unless you want to pay a good portion out of pocket.

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    #4
    Quote Originally Posted by TrishAFSpouse View Post
    If you are on prime and go to a location that is not authorized then you will get billed and Tricare will not pay. Generally, when a hospital or doctor says they take Tricare it is usually Standard, not prime. Prime has to be seen at an MTF, and if that MTF is more than 50 miles you can use Prime Remote, but you have to call Tricare in advance.

    So, if your parents are not near an MTF, or they are more than 50 miles from the nearest MTF, then you can go on Prime Remote and you would have the same options as Tricare Standard. And its 50 miles as the crow flies, point A to point B.. regardless if it takes more than 50 miles to drive there.

    If the place in Newark is less than 50 miles, then you will likely be stuck going there unless you want to pay a good portion out of pocket.
    If you don't have a referral and you go there, you'll have to pay it and submit a receipt it looks like. They will only cover what they are authorized, and you will pay the rest.
    "Obstinacy is a fault of temperament. Stubbornness and Intolerance of contradiction result from a special kind of Egotism, which elevates above everything else the pleasure of its own autonomous intellect, to which others must bow.: Carl von Clausewitz
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    #5
    "Obstinacy is a fault of temperament. Stubbornness and Intolerance of contradiction result from a special kind of Egotism, which elevates above everything else the pleasure of its own autonomous intellect, to which others must bow.: Carl von Clausewitz
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    #6
    Referrals don't always work with prime. The referral has to come from an approved doctor (i.e. one at an MTF or authorized prime doctor) and it has to be written as such that they must go to X instead of the MTF. If it isn't documented or worded correctly Tricare will/can deny it.

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    #7
    your best bet is to just switch to standard and choose where you want to go. VS Prime Remote (which is what you would be in NY) and trying to wiggle thru.

    this is coming from someone who works in the medical ins field.
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    #8
    Quote Originally Posted by TrishAFSpouse View Post
    Referrals don't always work with prime. The referral has to come from an approved doctor (i.e. one at an MTF or authorized prime doctor) and it has to be written as such that they must go to X instead of the MTF. If it isn't documented or worded correctly Tricare will/can deny it.
    She has to get approval from their new area. That is what the pdf document from tricare are says. Just going off that
    "Obstinacy is a fault of temperament. Stubbornness and Intolerance of contradiction result from a special kind of Egotism, which elevates above everything else the pleasure of its own autonomous intellect, to which others must bow.: Carl von Clausewitz
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    #9
    It wouldn't have to be prime remote though...there are a multitude of doctors (PCM not mtf they are all optional for my area and OB/gyns) available coming up for prime when I search online..and I'm afraid of the 'having to stay on standard for a year thing' so I don't want to switch to that but I will look into it.

    ugh this really sucks...my first baby and I most likely won't even get to go to the hospital my doctor delivers at and will have to be a hospital in a not so nice area.... or I drive like an hour (to get something a little more decent) and risk getting stuck in major rush hour traffic depending on the time. Bleh well I have some thinking to do I guess!!

    I'm seeing online that for standard there is a $300 family deductible, and then there's also this: What's the maximum I'll pay out-of-pocket? (Also known as the Catastrophic Cap.) Active duty families: $1,000 per family, per fiscal year.

    Would that mean the maximum I could pay for anything no matter what is $1000? . It also says this for prime as well.
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    #10
    anything over 50 miles from an MTF is slightly guided to go prime remote. it is going to be your best bet if you don't want to go standard.

    Enroll or Purchase a Plan - TRICARE Prime Remote

    just by entering in the zip 07101 from newark under prime remote and over 50 ob/gyn's with in 100 miles popped up. if you look under just prime you get like 8, 6 of which are all at the same location (the one im thinking you don't want)
    Florida girl in a Snowy World
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