Electronic Claims Filing

Benefits of Filing Claims Electronically
Electronic Claims Filing Options
HIPAA
Other Resources
 

• Improved cash flow - On average, TRICARE electronic claims process two to three weeks faster than paper claims.  This combined with the elimination of mail time means that you will receive your TRICARE payments much faster if you file your TRICARE claims electronically. 
• Reduced postage and paper handling costs
• Eliminates data entry errors
• Better audit trail - Electronic media claims (EMC) response reports show you which claims were accepted for processing.  Also, front-end EMC edits give you much quicker feedback regarding problems with your claims, allowing you to correct and resubmit quickly instead of taking weeks.
• Real-time claims processing - if you're using XPressClaim^SM  (more information below), you can submit your claims online and instantly find out how much TRICARE will pay. 
• Electronic remittance advice (ERA) and electronic funds transfer (EFT) - network providers who file all of their TRICARE claims electronically are eligible to receive ERAs and EFTs.

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Listed here are several options to review when choosing to submit your claims electronically.

XPressClaim
Imagine filing your TRICARE claims while your patients are still in your office and getting the payment results right away—that’s XPressClaim. It’s secure, easy to use, fast, and free. You can submit secure TRICARE CMS-1500 and UB-92 claims and receive instant results. You can also print a patient summary receipt on the spot, while your patient is still in the office. If you’re a member of the myTRICARE claims for Providers section of PGBA’s Website, you can access XPressClaim right now. (If you haven't already joined myTRICARE claims, follow the prompts for signing up.)

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• ASC X12N 837—Health Care Claim: Professional, Version 4010 and Addenda
• ASC X12N 837—Health Care Claim: Institutional, Version 4010 and Addenda

• If you submit your claims through a clearinghouse or other vendor, contact them and find out what steps are necessary in order for your TRICARE claims to be transmitted to PGBA in the HIPAA standard claims format.  If you submit directly to PGBA, your system will have to be able to produce the HIPAA standard claims format. Contact your software vendor to determine what changes are needed in your system and plan to test your updated software and migrate to the new formats as soon as possible.

Provider Trading Partner Agreement  - required by TRICARE for providers submitting electronic claims.

TRICARE Web site - offering additional information concerning HIPAA.

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EMC Help Desk
PGBA operates an EMC Help Desk to assist you with any issues related to TRICARE electronic claims submissions. The telephone number is 1-800-325-5920. When you call, be sure to identify yourself as a TRICARE provider.

Hard Copy Supporting Documentation
Did you know that TRICARE claims that require some type of hard copy supporting documentation can still be filed electronically? PGBA has a dedicated fax to receive supporting documentation for electronically submitted claims. There is an EMC Attachment Form that you should use in order to ensure that the documentation is correctly matched up to your claim.

TRICARE Provider IDs
In order to ensure correct claims payment, it is important that your claims be filed with the correct TRICARE Provider ID. The TRICARE Provider ID consists of your Tax ID with a possible 3-digit suffix.  If you have multiple office locations, each office location will have a different suffix. The suffix may also be used to distinguish departments within an institution (i.e. psych unit vs. medical/surgical). If you do not know your TRICARE Provider IDs, contact your Humana Military Provider Relations Representative. Including the appropriate office location suffix will ensure your check is mailed to the correct address.

On professional claims (CMS-1500) submitted by a group practice, the Rendering Physician ID must be submitted on each line of the claim. Note that this is a different number than the TRICARE Provider ID previously discussed. It is typically the SSN of the physician who rendered the service.

EMC Response Reports
To ensure that your electronic TRICARE claims are accepted by PGBA’s system for processing, it is imperative that you reconcile your EMC transmissions with the EMC response reports returned by PGBA for every transmission. These responses show you the claims that were rejected as well as the claims that were accepted for processing. Reviewing these responses will ensure that EMC transmissions are not lost, and that rejected claims are identified so you can correct and resubmit them electronically for processing.

If your TRICARE claims are submitted through a clearinghouse or other vendor, the PGBA responses are returned to that entity. Note that many clearinghouses perform their own edits and create their own reports which show how many claims were received from the provider and forwarded on to the payer, but only the PGBA responses show you which claims were received and accepted by PGBA for processing. If you are not sure if you are receiving these PGBA EMC responses, contact your vendor or the PGBA EMC Help Desk at 1-800-325-5920.

Common EMC Rejects 
Here you will find a listing of the most common EMC Reject Reasons and Solutions.
 

• 837 I/P Formats
• Legacy Formats

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