Claims Processing and Billing Information

Claims Processing Standards and Guidelines

All claims for TRICARE covered services must be submitted to PGBA for claims processing in accordance with the TriWest TRICARE Provider Handbook, no later than one year (365 days) after services are provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility or an ancillary provider participating in the inpatient care. To ensure timely submission and payment, TriWest strongly recommends filing claims within 30 days of the date of service. The claim must be submitted to PGBA within 90 calendar days from the date of the OHI adjudication.

TRICARE requires electronic claims be filed using the appropriate HIPAA-compliant and standard electronic claims format. If a non-network provider must submit paper claims, TRICARE requires use of either a CMS 1500 (professional charges) or a CMS UB-04 (institutional charges) claim form.

Completion of claim forms and claim form requirement information can be found online (specific link to be updated prior to start of health care delivery).

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Electronic Funds Transfer and Electronic Remittance Advice

TriWest providers can enroll online for ERA and/or EFT through the Availity Essentials Transaction Enrollment application (specific link to be updated prior to start of health care delivery). Your organization’s Availity administrator can set up user account access and assign roles and permissions to ensure you receive payments more quickly and avoid the hassle of paper checks and/or remits.

Enroll by following these steps:

• Log into Availity and navigate to Availity Essentials (specific link to be updated prior to start of health care delivery)
• Select My Providers > Enrollment Center > Transaction Enrollment
  • With Transaction Enrollment permission the user can enroll a single provider or providers in bulk (up to 500 at a time).

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TRICARE Billing Policies and Tips

Beneficiary Signature on File – Use of the signature on file procedure is the provider’s indication that he or she agrees that verification of the beneficiary’s TRICARE eligibility at the time of admission or at the time care or services are provided is required prior to any TRICARE payment.

Please refer to the TRICARE Operations Manual, Chapter 8, Section 4 to learn more about signature requirements.

Referrals – Network providers should hold beneficiaries harmless “held harmless” (i.e., considered not financially responsible for any charges) in cases where the providers fails to request a referral and the contractor either denies payment or applies Prime Pont of Service (POS) option.

Claim Processing Timelines – 98% of retained and adjustment claims will be processed to completion within 30 calendar days from the date of receipt. 

Other Health Insurance (OHI) – It is the provider’s responsibility to ask the beneficiary if they have Other Health Insurance that is primary to TRICARE and submit the claim to primary payer before claim is filed with TRICARE. If TRICARE receives claim before OHI processes it, the claim will be denied.

National Provider Identifier (NPI): Providers in a Group should submit claims with their individual and group NPI:

• Enter Type 1 NPI in CMS 1500 form Field 24J
• Enter Type 2 NPI in Field 33A as billing provider
• Solo Practitioners: Use individual NPI in Field 33A only

Corrected/Void Claims – A corrected claim should be submitted when you need to replace or correct information on a claim that was previously submitted and/or processed by PGBA. Submitting a corrected claim will have the effect of completely replacing your previously filed claim with the information on the corrected claim.

Examples of a corrected claim include (but are not limited to):

• Providing a referral number or rendering NPI originally omitted
• Changing procedure or diagnosis codes, or the patient’s name or demographic information, or any other information that would change the way the claim was originally processed

Submit a void claim when you need to cancel a claim already submitted and/or processed by PGBA.

How to File a Corrected/Void Claim – Corrected claims can be submitted electronically as an EDI 837 transaction with the appropriate frequency code.

When correcting information on 837 institutional claims, use bill type xx7, Replacement of Prior Claim or bill type xx8 to void a previous claim.

When correcting a paper CMS 1500 professional claim, use the following frequency codes in Box 22 and use left justified to enter the code. Include the 12-digit original claim number under the Original Reference Number in this box.

• Frequency code 7: Replacement of Prior Claim – Corrects a previously submitted claim
• Frequency code 8: Void/Cancel of Prior Claim – Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims

Billing duplicate services on same day: The same procedure code cannot be billed on multiple lines for the same date of service when no modifier is billed to distinguish the services because it is considered a duplicate procedure. Instead, please bill procedure code on one line with multiple units. If the same procedure was performed on different DOS, please bill each line separately instead of billing a date range on one line.

Emergency room charges with inpatient facility stay: Emergency room charges in conjunction with a DRG-reimbursed hospital stay must be billed on a separate outpatient CMS UB-04 form. In addition, ambulatory surgery room charges cannot be submitted on an inpatient facility claim and should be billed as a separate outpatient service on the CMS UB-04 form.

Interim claims: Interim bills are accepted when the beneficiary has been in the hospital at least 60 days. Please submit interim bills in chronological order.

Please refer to the TRICARE Policy Manual (TPM) to learn more about billing and policies surrounding specific types of care. The TPM is searchable by keyword.

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Claims Status Check

Providers can check the status of claims through Availity (specific link to be updated prior to start of health care delivery). The tool gives providers a more intuitive and robust workflow to check the claim status of a beneficiary. The Claim Status tool allows providers to check the status of a submitted claim and view remittances.

Providers can also search claims by:

• Member ID
• Tax ID Service date
• Claim number

If a claim cannot be found, there may have been errors with the submission. If a claim is visible, it is in process. Please do not resubmit for in-process claims.

For missing claims, please verify that:

• It has been at least 10 business days since you uploaded the claim or 15 business days since the provider mailed the claim
• A paper claim was not handwritten and all information was typed correctly

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Eye Exam Coverage

TRICARE Select ADFMs are entitled to one annual routine eye examination. Prime ADFMs may receive their annual routine eye examination from any network provider without referral, authorization, or pre-authorization from the PCM, or any other authority (i.e., a Prime ADFM will be allowed to set up his or her own appointment for a routine eye examination with any network optometrist or ophthalmologist). TRICARE Select ADFMs may self-refer to any TRICARE authorized provider regardless of whether or not they are a network provider (i.e., they may set up their own appointment with either a network or non-network, TRICARE-authorized, optometrist or ophthalmologist).

Routine eye exams are covered once every two years for retirees and eligible family members who are enrolled in TRICARE Prime. Routine eye exams are not a covered benefit for retirees and eligible family members who are enrolled in TRICARE Select. Active duty family members who are enrolled in TRICARE Prime or TRICARE Select may receive a routine eye exam annually.

Please refer to TRICARE Policy Manual (TPM), Chapter 7, Section 6.1 to learn more about Ophthalmological services.

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Non-Covered Services

It is the provider’s responsibility to ensure services are covered prior to delivering care. Non-covered services include:

• Services that appear on the No Government Pay Procedure Code List
• Services outside of the scope of TRICARE-covered services
• Services that currently have a temporary code or are considered experimental

If services are considered non-covered, providers must notify TRICARE beneficiaries in writing before delivering care.

In certain circumstances, ADSMs may be approved for non-covered services if authorized or a waiver is received from MTF.

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Processing Claims for Out of Jurisdiction

For beneficiaries not enrolled in TRICARE Prime, the provider will submit claims to the contractor responsible for the jurisdiction using the beneficiary’s home address on the claim regardless of where the service was received. (See the TRICARE Systems Manual (TSM), Chapter 3, Section 4.2, if the beneficiary’s home address on the claim differs from the home address on DEERS).

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TRICARE-Authorized Non-Network/Non-Participating Providers

Once you sign an agreement to become a TRICARE network provider, you agree to be paid the lesser of the TRICARE maximum allowable charge or your contracted rate. If you are a non-network TRICARE-authorized provider and have agreed to participate on a claim, this means you have agreed to accept the TRICARE-allowable charge as payment in full for this claim and you may not bill patients for any amount in excess of the TRICARE-allowable charge. Non-network providers who do not accept assignment are limited by federal balance billing laws on how much they can bill TRICARE beneficiaries.

By federal law, non-participating providers may not balance bill the beneficiary more than 15% above the allowable charge. When the billed amount is less than 115% of the allowed amount, the provider is limited to billing the billed charge to the beneficiary. The balance billing limit shall be applied to each line item on a claim.

See the TRICARE-allowable charge schedules for more information.

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TRICARE and Other Health Insurance (OHI)

TRICARE is always the primary payer for ADSMs (including National Guard and Reserve members). For other beneficiary categories, TRICARE pays secondary to Medicare and other primary coverage.

If TRICARE is the secondary payer, the provider is required to submit claims to the primary payer before billing TRICARE. Provider must include the OHI EOB with paper claim submission, or fill out appropriate COB loops and segments on the electronic claim submission.

TRICARE requires an acceptable reason from OHI for non-payment before a claim can be considered payable. To coordinate benefits, the EOB/COB must reflect the beneficiary’s liability (copayment, deductible and/or cost-share), original billed amount, allowed amount, and/or any discounts. The claim will be denied if there is indication of primary OHI and the claim is submitted without other payer EOB or COB payment information.

Other Health Insurance Claims

The below services require a TRICARE pre-authorization regardless of OHI:

• Adjunctive dental care
• Advanced life support air ambulance in conjunction with stem cell transplantation
• All inpatient TOS behavioral health and substance abuse disorder (SUD) services (inpatient services, SUD, substance use disorder rehabilitation facility, and RTC residential)
• All solid organ and stem cell transplants
• ABA services
• ECHO
• Electroconvulsive therapy
• Home health services, including home infusion
• Hospice
• Intensive outpatient programs
• Laboratory developed tests
• Low protein modified foods
• Medication-assisted treatment
• Non-emergency admissions, to include detoxification and rehabilitation services
• Open, arthroscopic, and combined hip surgery for the treatment of Femoroacetabular Impingement
• Opioid treatment programs (OTPs)
• PHPs
• Psychoanalysis
• Psychological testing
• Residential Treatment Centers (RTC)
• Transcranial Magnetic Stimulation
• Transplants (solid organ and stem cell, not corneal transplant)

Identify OHI in the claim form:

• Mark “Yes” in Box 11d (CMS 1500 claim form) or FL (CMS UB-04 claim form)
• Indicate the primary payer in Box 9 (CMS 1500 claim form) or FL 50 (CMS UB-04 claim form)
• Indicate the amount paid by the OHI in Box 29 (CMS 1500 claim form) or FL 54 (CMS UB-04 claim form)
• Indicate insured’s name in Box 4 (CMS 1500 claim form) or FL 58 (CMS UB-04 claim form)
• Indicate the allowed amount of the OHI in FL 39 (CMS UB04 claim form) using value code 44 and entering the dollar amount

Please refer to TRICARE Reimbursement Manual, Chapter 4, Section 3 to learn more about how TRICARE coordinates benefits.

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Ambulatory Surgery Center Charges

All hospitals or freestanding ASCs must submit claims for ambulatory surgery procedures on a CMS UB-04 claim form.

Please refer to TRICARE Policy Manual, Chapter 11, Sections 6.1 and 6.2 to learn more about Ambulatory Surgery and Freestanding Ambulatory Surgery Centers

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TRICARE and Workers’ Compensation

TRICARE will not reimburse services covered under workers’ compensation programs.

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Fraud and Abuse

TriWest utilizes pre-payment and post-payment fraud detection tools and resources to monitor and analyze various beneficiary, provider, and claim data for potential fraud, waste, and abuse. Providers are responsible for submitting accurate and appropriate billing for all services billed to TRICARE. An example of Fraud, Waste and Abuse includes billing for services, supplies or equipment not furnished or used by the beneficiary.

Please refer to TRICARE Operations Manual, Chapter 13, Section 2 to learn more about TriWest responsibilities pertaining to Fraud, Waste and Abuse.

Providers who wish to voluntarily disclose self-discovered potential fraud to Defense Health Agency – Program Integrity may do so under the Self-Disclosure Program (SDP). Disclosing Providers may report by sending information to Defense Health Agency – Program Integrity or may also report potential fraud online.

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