Provider Handbook

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All claims for the TRICARE Extended Care Health Option (ECHO) must have a valid written authorization.

All claims for ECHO-authorized care (including ECHO Home Health Care) that have been authorized under the ECHO program should be billed on individual line items. Unauthorized ECHO care claims will be denied.

ECHO claims shall be reimbursed for the amount authorized (indicated on the written authorization provided by Humana Military) or the monthly benefit limit, whichever is lower. Each line item on an ECHO claim needs to correspond to a line item on the service authorization, or the claim may be denied or delayed due to research and reconciliation.

The “billed amount” for procedures should reflect the service, not the benefit limit. Pricing of ECHO services and items is determined in accordance with the TRICARE Reimbursement Manual.

Note (for beneficiary-filed claims): If a beneficiary submits a claim for the use of a privately owned vehicle, the reimbursement rate is limited to the Federal Government employee mileage reimbursement rate in effect on the trip date, regardless of the number of ECHO family members being transported.

See Chapter 9, Sections 4.1, 11.1, 14.1, and 18.1 of the TRICARE Policy Manual for additional claims information.

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Claims for the Supplemental Health Care Program (SHCP) are processed and paid through PGBA. All TRICARE claims must be sent to the address below:
 

TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC 29020-7031

The same balance billing limitations applicable to TRICARE apply to the SHCP. For more information regarding balance billing, see the Important Provider Information section.

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• Claims must be filed electronically with PGBA on behalf of TRS members in the same manner as other TRICARE claims.
• Claims may be submitted through the Humana Military and PGBA Web sites.
• The cost-share for all TRS members, including the National Guard/Reserve member, is 15 percent of the negotiated fee for covered services from TRICARE network providers. TRICARE will reimburse the remaining amount of the negotiated fee.

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• Participation with TRICARE (e.g., accepting assignment, filing claims, and accepting the TRICARE allowable charge as payment in full) is encouraged, but not required, on TRS claims.
• Non-network providers are encouraged to submit their TRICARE claims electronically.
• The cost-share for all TRS covered members is 20 percent of the TRICARE allowable charge for covered services from non-network TRICARE-authorized providers. TRICARE will reimburse the remainder of the TRICARE allowable charge.
• If a non-network provider does not participate on a particular claim, members will file their own claims with TRICARE for reimbursement and then pay the non-network provider.

Note (for non-network providers): If a non-network provider does not participate on a particular claim, the provider may not charge TRS members more than 15 percent above the TRICARE allowable charge by federal law.

Visit the TRICARE Web site to locate the TRICARE allowable charge schedules.

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