Providing world-class health care to TRICARE beneficiaries is an important part of being a TRICARE provider. Staying on top
of the business side of your practice is a key component in your ability to care for TRICARE beneficiaries.

One of the easiest ways to keep your business moving is to avoid claim rejections and denials by submitting error-free TRICARE claims. If you are a TRICARE network provider, the first thing to remember about filing claims is that you must file your Accountability Act (HIPAA) compliant X12 electronically.Electronic claims must be filed in the Health Insurance Portability and ANSI837P (professional) 837I (institutional) formats.

Non-network providers can still use the CMS-1500 or UB-04 paper forms, but they are encouraged to submit claims electronically.

At least 95 percent of “clean claims” are processed within 30 days to help you keep your practice running smoothly. A “clean claim” complies with billing guidelines and requirements, has no defects or impropriety, includes substantiating documentation (where applicable) and does not require special processing.

Some of the ways to make sure your claims are submitted “clean” include:
 

• Use your National Provider Identifier on the HIPAA 837P or 837I electronic claim format, or the CMS-1500 or UB-04 paper forms.
• Always include your federal tax identification number in the HIPAA 837P or 837I electronic format; or in Box 25 of the CMS-1500 or Box 5 of the UB-04, your address and ZIP code in Box 32 of the CMS-1500 or Box 1 of the UB-04; and your “pay-to” address in Box 33 of the CMS-1500 if submitting by paper.
• If you are billing for care that may involve third-party liability (TPL)— diagnosis codes 800-999—include a Statement of Personal Injury— Possible Third Party Liability form, DD Form 2527. This form is completed by the patient and can be submitted in advance or at the time of submitting an electronic claim, or it can be attached to a paper claim.
• Do not use generic V codes for lab, radiology or preoperative services as a primary diagnosis.

Also, starting in the fall of 2007, the Outpatient Prospective Payment System (OPPS) reimbursement methodology is mandatory. OPPS will apply to outpatient services provided by covered network and nonnetwork providers. Note: The  implementation date may be impacted by legislation or other policy changes.

All Humana Military TRICARE provider claims must be submitted to PGBA, LLC for payment within one year of the date the service was provided.

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Created: July 9, 2007