Other Health Insurance (OHI) Questionnaire

Use this form to report OHI, any health insurance other than TRICARE, available to you or your family members.

  • If you had a break in OHI coverage, please include information about the previous OHI coverage.
  • Only report OHI that pays primary to TRICARE.
  • For more information, please visit Other Health Insurance (OHI).
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Date of Submission:

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Select the coverage you'd like to update or remove. *

OHI Information

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Date of Submission:

To update OHI coverage, edit the fields below that need to be updated. To remove coverage, enter an expiration date.

OHI Information

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Only delete OHI coverage if it was never part of your coverage.

If this OHI is no longer effective, please enter the expiration date.
Here is your current OHI coverage. If you need to make any changes, go back to the previous screen. To add new OHI coverage, complete the form below.

OHI Information

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Types of Coverage

Primary: Acts as your main insurance coverage and pays primary to TRICARE.

Supplemental: Pays after TRICARE (i.e. Medicaid, Other Federal programs). More about Supplemental Insurance

Medicare Part A: “Hospital insurance” portion of Medicare that primarily covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.

Medicare Part B: Medical insurance portion of Medicare that covers outpatient services, doctor visits, preventive care, and durable medical equipment.

Visit this FAQ to see which plan (Medicare, TRICARE, or Other Health Insurance) pays first. How Medicare works with OHI


Fields marked with an asterisk ( * ) are required.
Date of Submission:
If you do not know your policy number, leave this field blank.
If this OHI is no longer effective, please enter the expiration date.
Please select at least one benefit.

Dental / Pharmacy / Medicaid is not applicable.

Please select at least one person covered by this policy.
Fields marked with an asterisk ( * ) are required.
Date of Submission:

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Date of Submission:

PRIVACY ACT: Authority: 10 USC Chapter 55; 32 CPR Part 199; and E.O. 9397 (SSN), as amended. The information collected may be disclosed for routine uses including: coordination of benefits, claims processing, providing eligibility, enrollment, fraud and abuse reviews, third party liability, quality assurance and responding to general customer inquiries. Appropriate disclosures may be made to healthcare providers, peer review committees, government agencies consistent with their statutory administrative responsibilities under TRICARE, to the Department of Justice for representation of the Secretary of Defense in civil actions and to Congressional Offices in response to inquiries made on the request of the person to whom a record pertains. Disclosure is voluntary; however, failure to provide information may result in a delay or denial of your claim or inquiry.

The statements made above are true and correct to the best of my knowledge. I understand that federal laws 18 U.S.C. 287 and 1001 provide for criminal penalties for submitting or making false, fictitious or fraudulent statements or claims in any matter within the jurisdiction of any department or agency of the United States. I further understand that copies of the laws cited may be obtained from uniformed services legal offices, public libraries and many Beneficiary Counseling and Assistance Coordinators.

How TRICARE Works with Other Health Insurance

Active Duty Service Members
Active duty service members (including activated National Guard and Reserve members) can't use other health insurance as their primary insurance. TRICARE is the primary payer and coordination of benefits with other insurance carriers does not occur.
Active duty service members who have other health insurance (OHI) require an approval from TriWest Healthcare Alliance for all services.
All Other Beneficiary Categories
All other beneficiaries with OHI (excluding Medicare) only require pre-authorization for applied behavior analysis services.
The OHI must be used before TRICARE. Health coverage through an employer, association, private insurer, school health care coverage for students, or Medicare is always primary to TRICARE.
Exceptions are: Medicaid, State Victims of Crime Compensation Programs, Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA), the Maternal and Child Program, the Indian Health Service, and plans specifically designated as TRICARE supplements.
If you have any health insurance other than TRICARE, it is called "other health insurance" or OHI. Find additional details at www.tricare.mil/plans/ohi.
Updating OHI
If your OHI changes, please update your OHI information. Losing or gaining OHI is considered a qualifying life event (QLE).
If you need immediate assistance with a prescription that was denied due to OHI Information, you may contact Express Scripts at 1-877-363-1303 for assistance.
How TRICARE Calculates Payment with Other Health Insurance
TRICARE requires coordination of benefits with OHI coverage. TRICARE does not always pay your OHI copayment or the balance left over after the OHI payment. However, you usually owe very little to nothing. The TRICARE payment calculation is based on the provider's status. Note: Most inpatient facilities have other calculations not listed below.
TRICARE Network Providers and Non-Network Providers Who Accept TRICARE Assignment (Participating)
TRICARE pays the lowest of:
  • Billed amount minus the OHI payment
  • Amount TRICARE would have paid without OHI
  • Amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)
Providers Who Do Not Accept TRICARE Assignment (Nonparticipating)
Nonparticipating providers may only bill the beneficiary up to 115 percent of the TRICARE allowed amount. If the OHI paid more than 115 percent of the allowed amount, no TRICARE payment is authorized, as the charge is considered paid in full and the provider may not bill the beneficiary. Otherwise, TRICARE pays the lowest of:
  • 115 percent of the allowed amount minus the OHI payment
  • Amount TRICARE would have paid without OHI
  • Amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)
Staff Model HMOs, Group HMOs and Other Capitated OHI Plan Providers
When you are enrolled in one of these OHI plans, the provider group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans, you generally only receive a co-payment receipt – an itemized bill or Explanation of Benefits (EOB) is not available.
In these cases, you submit a Beneficiary Claim Form DD2642 with a copy of the receipt and the copayment is considered the billed amount. Deductibles and cost shares are applied and you may not receive full reimbursement of your HMO copayment.
Important Things to Know
  • All requirements of the OHI plan must be followed. If the OHI denies a claim because OHI authorization requirements were not followed or because a network provider was not used, TRICARE will also deny the claim and you will be responsible for the denied charges.
  • The OHI must process the claim before TRICARE can consider the charges.
  • If the OHI denies the claim for services not medically necessary, all appeal rights with the OHI must be used before TRICARE can process the claim.
  • Services must be provided by a TRICARE network or non-network provider.