Involving a debt collection agency to resolve a claim issue is stressful for both providers and beneficiaries. Fortunately, TRICARE offers assistance that you can take advantage of prior to sending a bill to a collection agency.

“It is never TRICARE’s intent not to pay the provider or send someone to collection,” says Francine Forestell, director of TRICARE beneficiary services and staff training. “It’s about following up and finding out what, if anything, went wrong, and then taking steps to resolve it.

Most rejected claims are due to a simple error. Do the following first to determine what might have gone wrong:
 

• Read the TRICARE Summary Payment Voucher, otherwise known as the remittance advice. If the claim is rejected, the remittance advice denial codes will explain why. 
• Make sure all beneficiary information is up to date. If patient or sponsor information is incorrect, contact the beneficiary and get the information needed. 
• Then find out if it’s an eligibility issue. If so, call your regional contractor, Humana Military, to get eligibility information. 
  

Even if you are a provider who is unwilling to accept assignment, it is a good practice to submit claims for TRICARE patients. Few beneficiaries understand the claims submission process and long delays in payment may occur as the beneficiary attempts to get adequate information to submit a claim.

It also helps to ask your staff to double-check for errors before submitting claims. The following are the most common mistakes:  
 

• Incorrect beneficiary address
• Incorrect Social Security number (SSN)—Do not submit under the beneficiary’s SSN unless that person is the military ‘sponsor’ or the person is an eligible former spouse.
• Wrong procedure and diagnosis codes (For example, V70.0 is not an appropriate diagnosis code; V72.6 is not appropriate for a lab test. If the care was preventive, use a preventive diagnosis code. Unclassified [Physician’s] Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes should be used only with a clear description of what is being billed.)
• Unpaid copayment  
  

If you discover a problem, take quick action to resolve it within the TRICARE system rather than sending the issue to collections. Humana Military is your first point of contact for resolving claims issues. In most instances, Humana Military will be able to resolve your issue or concern. Call 1-800-444-5445.

If the problem cannot be resolved at the regional contractor level, TRICARE providers can refer beneficiaries to beneficiary counseling and assistance coordinators (BCACs) first, then to debt collection assistance officers (DCAOs) if necessary. Both will help the beneficiary understand what’s going on with the claims issue and try to resolve it.

DCAOs help beneficiaries evaluate the validity of collection agent claims and/or the negative credit reports that sometimes result from them. DCAOs are well equipped to deal with these situations and, in the process, help ease the stress on service members and their families. For example, it’s the DCAO’s job to initiate contact with the collection agency and assure the agency that action is being taken to resolve the issue.

Sometimes, when acting as the beneficiary representative, the DCAO may even contact you. “Then any information you as a provider can give to help resolve an outstanding claim issue is greatly appreciated,” notes Forestell.

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Last Reviewed:  February 13, 2007