Tricare Claim question

So, I have Tricare Prime. Therefore, a long as it's requested by either my surgeon or my PCM and I get a referral for it, I'm covered. I just got a claim in the mail for $630.00 bucks. Saying that's my patient responsibility for the anesthesia from my EGD. They covered everything but that. Now, I know other people who had some sort of WLS with Tricare through the same surgeon and they all said they didn't have to pay a penny. This is the second thing I've gotten with "Patient responsibility" on it saying it's non-covered by Tricare. (the first being my Psych Eval but I appealed that) Now, both times it's just said "Obesity is non-covered." So, is it the doctor just not putting in the right code for the claim or what? Who should I call. Cause I'm certainly not paying $630 bucks when others that have gotten the same exact surgery have paid $0. Should I just appeal this one as well?

Ah, so nevermind. Apparently the doctor's office must have re-submitted it under a different code cause I just got a letter today saying it was covered. Phew! *wipes forehead*

so i was wondering, have you had to pay anything out of pocket except for the co-pays of $12.00? i am also on tri care prime and i am just starting this, and i got from my surgeons office, an estimated amounts due that are out of pocket, they said $612 for the surgeon for his deductalbe and what ever the anesthes is that is not covered or what ever thier deductable is...and it said i had a $25/00 co pay for the hospital overnight stay which i knew i had that but....i am not sure about the other $600 as a deductable to the surgeon.
i only have 2 drs to choose from and this one is one of them,

thanks so much for your help,
debby

I found this on Military Times Tricare Help Blog.  Hope it helps.

Why does my doctor keep billing me?

JANUARY 25TH, 2010 | TRICARE HELP | POSTED BY MILITARY TIMES

   

Q. My doctor charged $268. Tricare allowed $192.50 and sent me a check for 75 percent, or $144.38. I paid the doctor $192.50 plus the 15 percent surcharge, for a total of $221.38. Now the doctor is demanding another $46.62, making the total the amount of his original bill, and says he’ll turn my account over to a collection agency if I don’t pay. It’s my understanding that federal law doesn’t allow him to do that. What should I do?

You are correct. The doctor may not charge you more than 15 percent over the amount Tricare allowed. If he sees Medicare patients, he is aware that the Limiting Charge law applies to Medicare claims; he needs to learn that it applies to Tricare claims also.

You should send a report to the Tricare office that processed your claim. The address is on the Tricare Explanation of Benefits form. Include a copy of the EOB and any “balance due" notices from the doctor. If the doctor persists, report him again.

It is unfortunate that the law will not allow Tricare to do more than write to the doctor and explain the federal law. Beyond that, all it can do is threaten to discontinue his status as a Tricare-authorized provider and threaten to cancel his ability to participate in other federal programs such as Medicare.

The doctor may be unaware of what his billing clerk is doing. You might consider writing or talking with him about it.