Uniformed Services Family Health Plan

Uniformed Services Family Health Plan (USFHP) is a Department of Defense-sponsored health plan through TRICARE, serving eligible military families, for which Tufts Health Plan provides administrative services. Providers rendering services to USFHP members are subject to TRICARE reimbursement policies and regulations. For information on TRICARE’s reimbursement policies and regulations, refer to the TRICARE Manuals Online. (Note: Providers should reference the 2015 editions)

For additional information regarding policies and procedures, including claims submission and appeals, refer to the USFHP Provider Manual.

What is TRICARE?

TRICARE provides comprehensive coverage for uniformed service members and their families around the world, including:

• Active duty and retirees
• National Guard/Reserve members
• Family members registered in the Defense Enrollment Eligibility Reporting System (DEERS)
• Former spouses and survivors and of deceased service members
• Medal of Honor recipients and their families

USFHP meets the requirements for minimum essential coverage under the Affordable Care Act. For more information on coverage and eligibility, refer to the USFHP website.

Relationship with Tufts Health Plan

Tufts Health Plan is contracted with USFHP as a third-party administrator to process claims, referrals and authorizations, as well as offer care management and member service support. This affiliation provides members with access to a select network of providers and hospitals, as well as to specialty and ancillary providers.

Members are supported by the Tufts Health Plan Clinical Support programs. Providers that feel a member with complex medical needs would benefit from working with a nurse care manager can make a referral by calling 888.766.9818, ext. 53532.

Compensation/Reimbursement Information

Rates for services for USFHP members are determined by TRICARE and are updated annually. The rates and coverage may differ from Medicare. Please note that TRICARE DRG methodology is used for inpatient facility pricing, while Medicare OOPS methodology is used for outpatient facility pricing. For updated information about codes that may or may not be covered under USFHP, refer to TRICARE’s No Government Pay Procedure Code List.

Under TRICARE, payment will not be made for procedures that are designated as “Inpatient Only” if billed with a different place of service. This list may differ from Medicare. The list of HCPCS Codes can be found at: Inpatient Procedures | Health.mil

If you have detailed questions on your reimbursement rate, please contact your Tufts Health Plan Provider Enrollment representative, or US Family Health Plan Customer Service at 1-800-818-8589.

Billing Information

When billing services for USFHP members, providers are reminded not to bill Medicare for services covered by USFHP.

Medicare may be billed only for services not covered by USFHP, e.g., end-stage renal disease. For such instances, Medicare should be billed first, followed by USFHP. For a list of services covered by USFHP, refer to the TRICARE Guidelines.

USFHP cannot compensate for claims that have been billed to and compensated by Medicare. Providers must first reimburse Medicare for any previous payment made in error, and must then bill USFHP for compensation of those services.

Any private health insurance, with the exception of Medicare Supplement plans, should be billed prior to billing USFHP. This includes federal and state employee insurances.

Note: Providers are reminded to check the member’s ID card to identify USFHP members.

For additional information, refer to the Billing section of the USFHP Provider Manual or call Provider Services at 800.818.8589.

Medical Necessity Guidelines

For coverage criteria applicable to USFHP, refer to the Commercial medical necessity guidelines available in the Resource Center.

Note: Medical necessity guidelines that apply only to USFHP are labeled.