Getting the most from Tricare for HB...HELP! - Mothering Forums

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#1 of 3 Old 05-03-2011, 03:38 PM - Thread Starter
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I am trying desperately to jump through Tricare's hoops but keep getting knocked down at every turn. 


I am on Tricare-Prime Remote. I am in an area (SF bay area) where there are a lot of CNMs in my network. However none of them do HBs. So I found an CNM that is out-of network that does HB and got a referral to her from my PCM. Tricare denied it saying that she wasn't found in their system as certified. I had her send in her info, tax id #, cert # the works. They said they aren't showing this info but that I am okay to see her for my care but as a POS (point of service) care provider. This would mean paying 300.00 deductible and then 50% of remaining. 


So my CNM charges 4700.00 so if they allow this then I would pay around 2500.00 out of pocket. I am wondering if it would be cheaper to switch to Standard and continue to see her? Its my understanding that I would pay a copay and then only 20% of allowable charges. This is where it gets sketchy...whats allowable? Will they tell me this amount if I call and ask? I have seen on older threads that they will pay 1500.00 for standard which would mean I would be left with 3200.00.


 Has anyone else had problems with this? Should I keep fighting to get it covered under Prime-remote?


I am super frustrated here. I was hoping they would cover around 3000.00 but its looking less and less like that will be the case. Any help or insight would be greatly appreciated. 


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#2 of 3 Old 05-09-2011, 08:11 PM
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I am in the same boat. prime remote and trying to get my hm CNM to be covered. I am waiting on a call back. I'm hopping they will allow the referral since the hospital CNMs don't do home birth. I have heard that tricare will only pay 1500 which would stink especially since they paid 5k for my unmedicated hospital birth a few years ago. I asked about that and they said it had to do with billing codes and of course the place that handles billing codes does not have a phone number only a mailing address for questions. wish I could be of help. I will be calling again tomorrow to see what I can find out.

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#3 of 3 Old 05-10-2011, 04:12 PM
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With Standard TriCare only pays $1500 for a homebirth. There is something about how a HCP cannot charge more than 15% above the usual and customary fee for a service, which means that you would not have to pay more than your deductible, copay and that 15%. I don't know how the $1500 that TC pays falls into that usual and customary fee. In other words, I don't know if the $1500 is the usual and customary fee and with Standard you would pay your deductible, copay and 15% (if your hcp charges you that) and then TC pays the difference between that and $1500 or if the usual and customary fee is, for example, $3000 and you would have to make up the difference plus possibly an additional 15% of the difference after the $1500 TC payment. I hope that makes sense.

It may also be that TC pays $1500 toward the actual birth but also covers prenatals on a per appointment basis. In that case, if your midwife knows how to bill, she could get paid for each prenatal plus the $1500 for the birth. That might mean that your deductible and copay total would end up being less with Standrad. That's something to specifically ask about at TriCare. I would ask to speak to a supervisor rather than just a regular customer service rep. They don't always know all the rules.

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