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Humana Military and PGBA want to help all TRICARE providers have a better understanding of claims processing procedures. To reach that goal, we’ve developed the following resources:

Web Sites
You can obtain the latest information about claims processing, check the status of claims and more, also in the Online Provider Services section. Registered users of either the Humana site or the PGBA Web site (www.myTRICARE.com ) can also submit claims electronically.

IVR System
When calling is more convenient, you can use Humana Military’s interactive voice response (IVR) system by calling 1-800-444-5445, or you can call PGBA at 1-800-403-3950 and speak to a provider representative to check on the status of claims, confirm the eligibility of a beneficiary, get an explanation of benefits and obtain pricing.

Remit Forms
Another way to ensure a smooth claims processing experience is to review all provider remits closely. The remit form is now easier to read, and it explains how to get a claim reconsidered satisfactorily.

ClaimCheck
During claims processing, PGBA uses the ClaimCheck® system to review claims and ClaimReview®, an automated module in ClaimCheck, to check for inconsistencies with TRICARE-covered services. For example, the system will compare the procedure code with the diagnosis code. If the codes are inappropriate for each other, the claim will be denied and the remit will say, “Diagnosis Code and Procedure Code combination non-specific or unrelated.”
To avoid such denials, and improve claims submission accuracy, your staff should review the Claims Processing and Billing chapter of the TRICARE Provider Handbook.

Requirements When Dual-Eligible Patients Seek Behavioral Health Care  (Article 9)

Behavioral health care providers should be aware of the requirements for dual-eligible beneficiaries, those eligible for both Medicare and TRICARE, seeking behavioral health care.

Submitting Claims
For dual-eligible beneficiaries, TRICARE pays secondary to Medicare. (Exception: For active duty family members (ADFMs) who are dual eligible and only have Medicare Part A, TRICARE is the primary payer for outpatient services.)
All TRICARE dual-eligible claims are processed by a single, nationwide claims processing contractor— Wisconsin Physicians Service TRICARE For Life (WPS-TFL).

Since Medicare is the primary payer to TRICARE, behavioral health providers who care for these beneficiaries should continue to follow Medicare rules for claims processing and submit your dual-eligible claims to Medicare first. Medicare then pays its portion and electronically transfers these claims directly to WPS-TFL.

Certain licensed providers are not recognized by Medicare, including licensed mental health counselors (LMHCs), licensed professional counselors (LPCs) and pastoral counselors (PCs). These providers should submit electronic claims for beneficiaries eligible for TRICARE and Medicare to WPS-TFL at www.tricare4u.com or paper claims at the following address:

Claims Submission
Wisconsin Physicians Services
PO Box 7890
Madison, WI 53708-7890

Obtaining Prior Authorizations
Prior authorization is not required for outpatient behavioral health services for beneficiaries eligible for TRICARE and Medicare.

Authorization is also not required for inpatient behavioral health care, but providers should be aware that the Medicare lifetime inpatient benefit is different for each level of care.  Therefore, if a beneficiary has exhausted his or her Medicare lifetime benefit or his or her fiscal TRICARE benefit, then authorization is required. Authorization can be obtained from Humana Military’s behavioral health care subcontractor, ValueOptions, by calling 1-800-700-8646.

Please note that ValueOptions does not authorize care for any dual-eligible beneficiary until he or she has exhausted the Medicare benefit. At that point, TRICARE would become primary payer, and ValueOptions would authorize inpatient care under the same process used to authorize inpatient care for TRICARE Standard beneficiaries. This procedure applies to inpatient services only because outpatient services for mental health do not have a benefit limit.

Also note that ValueOptions does not issue authorizations for LMHCs, LPCs or PCs to provide services to dual-eligible beneficiaries.

For more information, providers can call WPS toll-free at 1-866-773-0404, visit www.tricare4u.com, or mail inquiries to the following address:

Customer Service
Wisconsin Physicians Service
P.O. Box 7889
Madison, WI 53707-7889