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.
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.
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.
SAHM to 3 boys and 1 man; 22 , 9, 5 and now 1 year old!