To child

How To Get Tricare to Add a Provider?

Is that even possible? Dh and I are going to TTC when he gets home in September. There's a CNM in town who does homebirths. I haven't met her yet but from reading her website I think we'll be a great match. We're Tricare Prime and they have several CNMs that are in network but do not do homebirth. My understanding is that since Tricare says they cover homebirth and none of their network providers will do it then they have to send me out of network for coverage. However I e-mailed the midwife and asked her and she said she's had dozens of tricare patients and none have gotten Tricare to cover it at all!
Her fees are pretty good but it's still not something I can afford completely out of pocket. There is a freestanding birth center here that is covered 100% which is better than a hospital but I really just want a homebirth.

^_^:
i'm not really sure how to get tricare to take someone on as a provider, but they just requested that my midwife become one.
you're right about tricare's policy on homebirth, they do cover it, and they covered my last birth and are currently covering this pregnancy with my CNM as an out of network provider. they gave me a lot of trouble, but you just have to be persistent. call them up, don't ask them to cover it, tell them they have to. you'll probobly get "we have CNMs in network, so you have to use one of them" a hundred times, just tell them the midwives they have in network don't provide the service you need, and this one does. then ask for their supervisor, and theirs, and on and on. eventually you'll get a letter in the mail saying it's covered. they may not pay your midwife's whole fee, but you can send in a claim for what you pay out of pocket, and they should reimburse you. though (of course) you might have to send in the claim a dozen times. :)

^_^:
The CNM has to fill out the paperwork required to become a provider. That is totally on her but I have heard it is a pain. Also they might want to negotiate her fee and I don't know if she would be down for that. I think the forms are on their website...i don't know. She would have to look there or call.
Have you thought about switching to standard? You could go to her then. The most you will spend per year is 1000 per family catastrophic cap. That includes all prescriptions and all your copays everything! Comes in handy when you want a vax friendly ped. Once you switch to standard though, you are locked in for a year. If someone does not accpet standard, you just file it yourself. YOu can go to anyone as long as they have a license and you don't need a referral.
I don't think calling and demanding that they cover it will work. Although i did get them to cover my son's surgery under a non network provider when we had prime. I don't know how! Called everyday and just asked that they do a rate negotiation. You have to just ask for a higher up person and tell your sob story. It doesn't hurt to ask but i wouldn't count on it.
SWITCH TO STANDARD IF YOU CAN AFFORD A LITTLE OUT OF POCKET COST.

^_^:
I did this - used an out of network provider under Tricare Prime. Yes, tricare should cover it. Your logic is correct, they have CNMs in network but they don't do homebirth (the service you need) so you need to get approval to use an out of network provider. I actually printed out the list of CNMs in my 40mi radius (think this is the range you must be willing to travel to) and called them to verify they don't do HB.
My CNM also applied to become an in network Tricare provider however I still had to apply to use her as an out of network provider first because of the time taken for her to become an in network provider. I had to get prenatal care, and couldn't wait for them to approve her in network status. I think Tricare is supposed to do your application in 7-10 days, it might take 2 months for a CNM to be an in network provider.
The first thing is to get your PCM to write you a referral to your CNM for a "homebirth". Under Prime you must have the referral and the authorisation number from tricare before you go to the CNM. Now I had no troubles (suprisingly!) doing this but others have, one mom on here was denied it and told to use the hospital facilities! Your choice then is to fight or switch to Tricare Standard... Do go to your PCM, not the OB clinic - I think that's asking for trouble. Your PCM may say they can't do it, but of course they can, they do referrals all the time, they may need some convincing. Try and take in some Tricare documents that say Tricare covers homebirth as this is news to most doctors.

Assuming you get your PCM to do the referral, this then goes to some medical management team within your MTF/area (this is still under military system, not tricare yet) and they basically try to find some way to deny it (cause they don't want you to go out of the mil. system), but push, push, push and once you clear that hurdle, your request should be sent to Tricare. Then Tricare will evaluate it, and because you are requesting an out of network provider, a nurse manager has to negotiate a contract between your CNM and Tricare. I think this just involves Tricare bullying the CNM to accept their crummy rates... Then you should get an authorisation number and you're set to make your CNM appt.
So it's good you're starting early. It took me 10 weeks, the first 7 weeks of being pissed around, then 3 weeks to push the request through. I'd recommend you call each step of the way to push your request through - I find that homebirth is so odd to these people, it sits on their desk because they don't know what to do with it. Calling up and nudging them along helped (always ask to which dept your request will go next!) - also reminding them you'd like to start some prenatal care...
ETA: Tricare was absolutely wonderful in my area, no problems whatsoever. Problems come from the military side - getting the referral, the med. mngmt team trying to deny it etc...

^_^:
Thanks so much for the info ladies. I should have mentioned that we don't have OB care on base so everyone is referred off base as soon as you get the positive test.
Do you think I should e-mail this homebirth CNM and give her the link to the tricare website about the process of becoming an in network provider?

^_^:
I don't think calling and demanding that they cover it will work. it has worked for me (twice with midwives, and then again with my sons ped).
you ahve to remember that whoever your talking to is paid to tell you no. you have to fight to get things covered sometimes. a lot of people will ask if something is covered and give up when they get an implied no, or even if they just get put on hold for too long. insurance companies don't want to pay for anything, period. and it's really easy to not pay for homebirths because people assume that they don't have to.

^_^:
it has worked for me (twice with midwives, and then again with my sons ped).
you ahve to remember that whoever your talking to is paid to tell you no. you have to fight to get things covered sometimes. a lot of people will ask if something is covered and give up when they get an implied no, or even if they just get put on hold for too long. insurance companies don't want to pay for anything, period. and it's really easy to not pay for homebirths because people assume that they don't have to. Thanks, that's really good advice and a good way to think about it. I am ready for the fight. I just wish there was some way to get it going before I am even pregnant you know? I get so darn hormonal when prego and I cry at a drop of a hat...so I know I'll be on the phone with these people just sobbing my eyes out lol.

^_^:
I just wanted to respond to let those who have been writing here that I stumbled upon this thread from a google search, read the whole thing and had to join just to reply.
I'm a Navy wife and we are preparing to start trying to conceive and I have just recently found out that the one midwife in all of South Texas takes Tricare, but am uncertain about whether I should switch to Tricare standard. I am aware that I can possibly get a referral, but need more information on something.
Prime pays 100% of the allowable charge. Standard pays 80%. But is that 80% of the allowable charge or of the ACTUAL charge? Even if I stick with Prime I'll have out-of-pocket expense b/c the CNM won't have enough covered by Tricare so this is an important thing for me to determine.
Also, there is an Integrative Medicine doctor that I use for well-woman exams and she's not in-network. As far as I know there are no in-network Integrative MD's in S. Texas. That's a factor for me to consider on whether or not to switch to Standard.
Thanks for any input on this.
It's great to find this forum.

^_^:
I have always found the Tricare reps on post to be really wonderful. They have been super friendly and walked me through the steps of everything. I would really recommend giving them a shot and maybe they can give you exact instructions or help you out. It was called the Tricare Patient Service Representative or something. Remember that even if you are going out of network for a homebirth you are probably still saving them money- they should go for it! GL to you!

^_^:
I just wanted to respond to let those who have been writing here that I stumbled upon this thread from a google search, read the whole thing and had to join just to reply.
I'm a Navy wife and we are preparing to start trying to conceive and I have just recently found out that the one midwife in all of South Texas takes Tricare, but am uncertain about whether I should switch to Tricare standard. I am aware that I can possibly get a referral, but need more information on something.
Prime pays 100% of the allowable charge. Standard pays 80%. But is that 80% of the allowable charge or of the ACTUAL charge? Even if I stick with Prime I'll have out-of-pocket expense b/c the CNM won't have enough covered by Tricare so this is an important thing for me to determine.
Also, there is an Integrative Medicine doctor that I use for well-woman exams and she's not in-network. As far as I know there are no in-network Integrative MD's in S. Texas. That's a factor for me to consider on whether or not to switch to Standard.
Thanks for any input on this.
It's great to find this forum. If your provider accepts Tricare PRIME then they can not charge you, they must accept what Tricare pays them. If she is charging you on top of that then what she is doing is illegal. That's the benefit of being prime, no costs whatsoever. For standard it would be 80% of the allowable charge.

^_^:
If your provider accepts Tricare PRIME then they can not charge you, they must accept what Tricare pays them. If she is charging you on top of that then what she is doing is illegal. That's the benefit of being prime, no costs whatsoever. For standard it would be 80% of the allowable charge. Yep that's right. I remember feeling bad for my CNM when I saw how much Tricare actually does pay.
Jessica B., I suppose you could offer your CNM something on the side, but the CNM cannot ask for more. The last step before the authorisation number is given is that a Nurse from Tricare negotiates the contract b/w Tricare and the CNM and part of that is the CNM agrees to Tricare's terms.
You could also just buy her a really nice gift.
If your CNM has to refer you anywhere during the pregnancy (e.g. I had a Level II ultrasound done), you also have to find a provider in network. I actually ended up using the MTF to get my ultrasound done because there wasn't a provider to do that any closer - the MTF wasn't happy about that - but Tricare forced them to take me :) Tricare main office was actually very helpful.

^_^:
Has anyone in the DC area, actually ben able to do a homebirth and still be on Prime? Wombat, I see you are in MD, were you able to get Bethesda to referr you off or did you have to switch to Standard?
I'm recently pregnant and switched to Standard for my last delivery, but I have thyroid problems and wasn't getting pregnant, so I switched back to Prime and (of course) got pregnant right away! I would love to just deliver w/my homebirth CNMs and have Prime pay for it, but I've heard that it is hard to get Bethesda to release you (if not impossible). So anyone have any stories????

^_^:
Yep that's right. I remember feeling bad for my CNM when I saw how much Tricare actually does pay. How much did they pay? Just curious. I'm going back and forth over whether or not I want to switch to Standard. I already know how much the CNM charges so this way I could figure out an estimate of my out of pocket costs.


More Topical:





copyright 2012 www.tochild.com

Home

Adoption

After birth

Baby bed

Breastfeeding

Child health

Childhood

New born babies

Nutritionally balanced

Parenting

Pregnancy and childbirth

Raising children

Teach hildren