TRICARE network providers must file patients’ TRICARE claims, even when a patient has other health insurance, and all claims must be filed electronically. Here are a few tips to improve your claims filing success.

Accurate Coding

When filing claims, you and your staff should use the current procedural terminology (CPT) or health care procedural coding system (HCPCS) codes that most accurately describe the procedure or service involved. You should not select codes that approximate the service involved. You should also avoid using unlisted or miscellaneous codes. Diagnosis code(s) must correlate with the procedure chosen. It is important to choose diagnoses codes to the 4th or 5th digit code specificity for clean claim processing justifying the services. Add screening codes where appropriate to assist in determining the reasons for the procedures performed. 

ClaimCheck Standards

When reviewing claims in the South Region, Humana Military and its claims-processing partner, PGBA, use ClaimCheck® software, which evaluates claims for coding appropriateness and seeks to eliminate overpayment on professional and outpatient claims.

ClaimCheck is designed to identify and reimburse services correctly. Please note the listed edits below for an understanding of the ClaimCheck edit rationale. PGBA updates ClaimCheck annually with new coding based on current industry standards.

To prevent ClaimCheck from denying claims, follow CPT coding guidelines. If ClaimCheck makes any edits, the edits will be explained on the remittance advice. Edit categories include the following:

In some cases, you may want a medical review to reconsider ClaimCheck edits. If so, you may request verification that the edit was applied correctly by asking for an explanation of ClaimCheck auditing logic. You can also submit documentation showing that unusual circumstances existed.

When seeking medical review or to provide additional documentation, you should write to:
 

TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032

ClaimReview

A module within ClaimCheck, called ClaimReview®, allows PGBA to ensure that the diagnosis and procedure codes match.

To avoid claim line denials, you should assign a diagnosis code that represents the reason why the procedure has been performed and any other diagnosis that would affect the patient’s treatment plan.

If a line on the claim is rejected, you should review the medical documentation for any additional diagnosis, and if found, submit the documentation on a corrected claim. If after review, other diagnoses cannot be found, a reconsideration can be requested by sending supporting medical record information to the TRICARE South Correspondence address.

If you have questions regarding claims editing, contact PGBA directly at 1-800-403-3950 or visit the PGBA Web site.

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Last Reviewed:  February 7, 2007