Understanding Insurance Order of Payment

Understanding Insurance Billing Order: Medicare, Medicaid, TRICARE, Indian Health Services, and Employer-Sponsored Insurance

When multiple insurance plans are in place, it is important to understand the proper billing order. This determines which insurer pays first and which pays last. Below is a breakdown of the correct coordination of benefits (COB) for Medicare, Medicaid, TRICARE, Indian Health Services (IHS), and employer-sponsored health insurance.

General Order of Insurance Billing

1. Employer-Sponsored Health Insurance (ESI) – If an individual has coverage through an employer or a spouse's employer, this is generally the primary payer.

2. Medicare – Medicare will usually pay after employer-sponsored insurance if the employer has more than 20 employees. If the employer has fewer than 20 employees, Medicare may be primary.

3. TRICARE – TRICARE is typically secondary to most other forms of insurance but will pay before Medicaid and IHS. If the individual is eligible for Medicare, TRICARE acts as a supplement unless the individual is actively employed and covered by ESI.

4. Indian Health Services (IHS) – IHS is the payer of last resort for enrolled Native Americans unless Medicaid is also involved. If other insurance exists, it must be billed first.

5. Medicaid – Medicaid is always the last payer and will only pay after all other insurances have processed the claim.

How Each Insurance Type Works Together

• Medicare and Employer-Sponsored Insurance:

  • If the individual is actively working and the employer has 20+ employees, employer insurance pays first, Medicare second.

  • If the employer has fewer than 20 employees, Medicare pays first.

• TRICARE and Medicare:

  • If eligible for both Medicare and TRICARE, Medicare is primary, and TRICARE for Life (TFL) is secondary.

  • If the individual is actively working and covered by ESI, the employer plan pays first, Medicare second, and TRICARE last.

• Medicare and Medicaid:

  • Medicare is always the primary payer, and Medicaid only pays after Medicare processes the claim.

  • Medicaid covers costs like Medicare premiums, copays, and services not covered by Medicare.

• TRICARE and Medicaid:

  • TRICARE always pays before Medicaid. Medicaid will only pay after TRICARE has processed and left an unpaid amount.

• Indian Health Services (IHS):

  • IHS pays only after all other eligible insurances have been billed.

Key Contact Information for Insurance Assistance

Medicare

• Website: https://www.medicare.gov

• Phone: 1-800-MEDICARE (1-800-633-4227)

Medicaid (Varies by State)

• Website: https://www.medicaid.gov

• Contact your state’s Medicaid office.

TRICARE (Managed by Regional Contractors, Updated for 2025)

• TRICARE East (Humana Military)

  • Website: https://www.tricare-east.com

  • Phone: 1-800-444-5445

• TRICARE West (TriWest Healthcare Alliance) - New Contractor as of January 1, 2025

  • Website: https://www.tricare-west.com

  • Phone: 1-888-TRIWEST (1-888-874-9378)

• TRICARE For Life (TFL) (Wisconsin Physicians Service - WPS)

  • Website: https://www.tricare4u.com

  • Phone: 1-866-773-0404

TriWest (VA Community Care Network)

• Website: https://www.triwest.com

• Phone: 1-866-651-4977

Indian Health Services (IHS)

• Website: https://www.ihs.gov

• Phone: 1-301-443-3024

Conclusion

Understanding the correct billing order for multiple insurance plans helps prevent claim denials and ensures proper coverage. Always verify benefits with each insurer and ensure providers submit claims in the correct sequence. Medicaid will always pay last, and TRICARE is secondary to most insurance except for Medicaid.

For further assistance, reach out to the contacts provided or work with a case manager to clarify specific scenarios.