Understanding Third Party Liability (TPL)

In the unfortunate event that you or your family is injured in an accident by a third party, it may be considered Third Party Liability. It is important to understand all aspects of Third Party Liability – including the necessary forms and claims processing procedures – prior to an accident. This knowledge will help save you time and money and will allow you to keep your focus should an accident occur.

What is Third Party Liability?

When a TRICARE beneficiary is injured as a result of an accident or the actions of a third party, TRICARE must consider possible liability prior to processing the claim. If appropriate, the government must pursue recovery rights available under the Federal Medical Care Recovery Act. If the liable third party has other health insurance (OHI) - including auto or homeowner's medical insurance, no-fault auto, or uninsured motorist coverage - that does not cover all expenses, TRICARE will coordinate as secondary coverage.

If the OHI pays the bill in full, TRICARE will pay nothing.

How do you know when to complete a Third Party Liability form?

When a claim is submitted for processing with certain diagnosis codes, you will receive a "Statement of Personal Injury – Possible Third Party Liability" form (DD Form 2527). If the TPL form is not received within 35 days of the initial request, the claim must be denied.

The decision whether or not to request a TPL form is based upon the diagnosis on the claim. All inpatient claims with a diagnosis code between 800 and 999 require an evaluation of TPL. The same is true for any outpatient claim with the same range of codes, in which the TRICARE liability exceeds $500.

The 800 to 999 code range includes fractures and dislocations, sprains, most injuries and wounds, contusions, possible complications of injury such as shock or embolism, poisonings, and complications associated with surgical or medical care. The completed TPL form enables TRICARE to determine whether or not to pursue a claim against the third party.

Why should you submit the TPL form?

Because TRICARE has no way of knowing if an injury was caused by a driver rear-ending you at a stop light, or whether you slipped in your own yard and injured yourself, completing the TPL form will help make the determination of how and when to process claims for payment.

Each claim in an episode of care is processed independently. If there is no connection between two or more claims on record, you may receive duplicate requests for a TPL form, so please make copies of all correspondence. Rather than try to locate lost or misplaced paperwork, it is often easier just to mail or fax another copy of this important form.

A copy of the DD Form 2527 can be downloaded and printed at www.triwest.com.

If you have a specific problem or question about this process, please contact a Beneficiary Counseling and Assistance Coordinator (BCAC) at the nearest military hospital or call 1-888-TRIWEST.

Online BCAC directory is available at http://www.tricare.osd.mil/BCACDirectory.htm

SOURCE: TRICARE Help E-Mail Service (THEMS).