Dealing with Tricare Line of Duty Claims

Some people, like me, are unlucky enough to get injured during military training while on HPSP. It all seems simple enough while you’re at the training course – you go to the medic, they patch you up, and you go about your day. But what happens when you need more care than that? What happens when you need physical therapy for that sprained ankle, or even surgery? The system that deals with that is extremely complex, and very few of the people you will come across will have any idea what to do with you.

What is Tricare Line of Duty coverage?

When you are on orders, you are on active duty, with all of the benefits (including Tricare military healthcare) that come with it. Once you go back to school, though, you go back into the inactive reserves, and your Tricare benefits disappear. Not only are you no longer covered by active duty Tricare, you can’t even buy Tricare like an active reservist!

So how do you get care? The answer is Tricare Line of Duty coverage.

Tricare Line of Duty coverage pays for health care that is needed due to an injury or illness that occurred while you were on active duty, and it gets you the same level of coverage for that particular illness or injury as you would have if you were still on active duty. Importantly, Tricare Line of Duty coverage is specific to one illness or injury – it does NOT pay for general medical care. So if you are granted Line of Duty coverage for a sprained ankle, Tricare won’t pay to refill your birth control pills.

How do I get Line of Duty coverage?

If you get ill or injured “in the line of duty” i.e. in training at a course that you are on orders for, such as Air Force Commissioned Officer Training, you need to make sure that injury is documented. The particular form that needs to be completed is a line of duty determination. This is a form completed by your chain of command to document that this illness or injury really did occur while you were on active duty. This form is the key to getting your medical care covered, and it’s a big pain in the rear end to go back and do it later, so if you get hurt, regardless of whether you think you will need further care for that injury, get this form filled out at the time of the injury. Otherwise, if you need care later and no one remembers you falling and hurting your ankle that day, the military doesn’t have to pay for it. When I had to get a line of duty determination, the form literally had a statement from my instructor stating that I told him I hurt myself and that I had been to the IDMT, and he didn’t think I was lying about it. It’s pretty straightforward, but it needs to be done.

How do I use Line of Duty coverage?

First, call your local Tricare office at your nearest base and talk to them. Tell them you are a reservist with a line of duty injury. They can help you determine whether you need to be seen on-base or not. If you are seen on-base and your area uses a central scheduling line, you can’t schedule your appointments that way. You need to make appointments directly with the front desk of the clinic where you will be seen. This is because Tricare line of duty coverage does not appear in their computer system as eligibility for care – the person scheduling the appointment has to manually override this and schedule you anyway. 

If you need to be seen off-base, call your regional Tricare contractor (find out who you need to call here). Again, tell them you are a reservist with a line of duty injury. They can help you coordinate referrals to off-base providers. Typically, you need a referral from a military provider in order to see a civilian provider, so you may need to get to a base at least once, or get a referral to a civilian from whoever saw you while you were on active duty.

What do I need to tell my doctor?

If you see a civilian, you need to tell them that you are receiving care under a Tricare line of duty determination. Give them the name and contact information of your regional Tricare contractor (see above) for billing. One of the civilian providers that I saw kept billing TriWest, which is the VA contractor, and kept getting the bills bounced back as “no coverage.” Well, duh! I don’t have any VA coverage!

What else do I need to know?

  • Whenever someone looks you up in a computer system, you will show as ineligible for care, because you don’t have Tricare coverage for general medical care.
  • Start every conversation, with a base or with Tricare, by saying “Hi, I am a reservist with a line of duty determination.” Why? Because this explains why you don’t show up as eligible for Tricare.
  • Tricare should cover everything related to your line of duty illness or injury, but they won’t reimburse care that you get outside of the Tricare line of duty system. If you use your own private health insurance for a duty-related condition, then you are out whatever it costs – deductibles, co-pays, etc.

 

What questions do you have about Tricare line of duty coverage?

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