OCFO : MC&FS : UBO : Billing : Forms, Military Unique
Tricare Home OCFO Home
Management Control & Financial Studies Division
Financial Studies Financial Systems Management Control Data Quality Management Control MEPRS UBO

UBO

Billing : Forms, Military Unique

Health Plan and Policy Billing Guidelines

There are several health coverage policies and plans to which cost recovery programs can submit claims. Claim formats that are used in the Military Health System (MHS) are based on encounter services provided, payer requirements, and Service and National Capital Region Medical Directorate (NCR MD) billing policies. The U.S. Government may not collect more than the total charge of medical care from any one source or combination of sources. If total payment received exceeds the amount billed, the MTF must refund the overage to the payer. The table below contains claim format guidelines for each UBO Cost Recovery Program.

Institutional – Hospital charges (routine service charges associated with the hospital stay and ancillary charges).

Professional – Provider charges (professional services provided by physicians and certain services provided by physicians and other providers).

Health Plan/Policy Institutional Billing Format Professional Billing Format Cost Recovery Program
Private Insurance Policy YES 837I/UB-04 YES 837P/CMS 1500 TPC, MSA, MAC
Employer Group Health Plan YES 837I/UB-04 YES 837P/CMS 1500 TPC, MSA, MAC
High Deductible Health Plan (HDHP) YES 837I/UB-04 YES 837P/CMS 1500 N/A
Health Savings Account (HSA) NO N/A NO N/A N/A
Health Reimbursement Account (HRA) NO N/A NO N/A N/A
Flexible Spending Account (FSA) NO N/A NO N/A N/A
Association or Organization Health Plan YES 837I/UB-04 YES 837P/CMS 1500 MAC
No-Fault Automobile Insurance YES 837I/UB-04 YES 837P/CMS 1500 MAC
Third-Party Automobile Liability (Tort Claim) YES 837I/UB-04 YES 837P/CMS 1500 MSA
Medicare Supplemental Plan YES 837I/UB-04 YES 837P/CMS 1500 MSA
Workers' Compensation Plan (Nonfederal Employee) YES 837I/UB-04 YES 837P/CMS 1500 MSA
Workers' Compensation Plan (Federal Employee) NO DD7/DD7A NO DD7/DD7A MSA
Workers' Compensation Plan (DoD Employee) NO N/A NO N/A N/A
TRICARE Supplement NO N/A NO N/A N/A
Income (Wage) Supplement NO N/A NO N/A N/A
Other/Special Coverage Group YES 837I/UB-04 YES 837P/CMS 1500 TPC, MSA, MAC
None (Pay patient) YES Invoice and receipt YES Invoice and receipt TPC,MAC

Back to Billing

Viewing or printing the PDF documents found on this site requires the use of Adobe Acrobat Reader, which you may download here. Get Adobe Reader