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Helpful Claims Processing Tips (Article 1) |
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Following these simple steps can help ensure your TRICARE claims are processed correctly the first time.
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Use the Correct TRICARE Sponsor’s Social Security Number
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Incorrect sponsors’ Social Security numbers (SSNs) frequently cause claims to be denied. Providers and staff should use the TRICARE sponsor’s SSN when filing a claim, unless the TRICARE-eligible beneficiary is the former spouse of a TRICARE sponsor. In that case, use the former spouse’s SSN. |
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Verify Patient’s Address |
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Service members move often. It’s common for providers to have an old or temporary address on file, so please ask beneficiaries to update their information during each visit. If their information has changed, also instruct them to update their information in the Defense Enrollment Eligibility Reporting System (DEERS) by calling 1-800-538-9552.
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Apply Accurate Coding |
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When filing claims, you and your staff should use the [Physician’s] Current Procedural Terminology or Healthcare Common Procedure Coding System codes that most accurately describe the procedure or service involved. You should not select codes that approximate the service involved, and you should avoid using unlisted or miscellaneous codes. All unclassified codes for services valued at more than $100 must have an authorization for payment to be made.
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Use Proper “V” Codes |
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 “V” codes are used to describe reasons other than disease or injury for seeing a health care provider. They are sometimes acceptable as the primary diagnosis for outpatient claims but rarely for inpatient claims. A “V” code can be submitted as the only diagnosis on a claim when it explains the reason for the visit, e.g., a routine infant or child health checkup or a preventive service.
TRICARE cannot accept a vague diagnosis such as V72-V82 for outpatient testing. Submit the referring physician’s working diagnosis if a diagnosis has not been confirmed. TRICARE can accept V22.2 for routine maternity testing.
If you are a behavioral health provider, please submit claims for behavioral health services using appropriate DSM-IV/ICD-9 diagnostic codes as the primary diagnosis. You may also include “V” codes as a modifying code to further explain the treatment provided.
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Other Health Insurance Claims |
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If the TRICARE beneficiary has other health insurance (OHI), remember to submit the claim first to the OHI plan, and then submit to TRICARE. Be sure to include the explanation of benefits (EOB) from the primary insurer with your claim. The primary EOB must contain the following:
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- Amount paid by the primary insurer
- Definition of any “reason codes” used by the primary insurer describing how the claim was processed
- Information on the action taken by the primary payer for each specific date of service and charges
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Claims submitted without this information will be denied. Find more information on claims submission requirements in your TRICARE provider materials
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Created: March 19, 2007
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