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All claims sent to Humana Military and its claims contractor, PGBA, LLC (PGBA), are reviewed by two automated systems: ClaimCheck®, which looks for inconsistencies with the claim, as well as ClaimReview®, which reviews the consistency of diagnosis and procedure codes provided on the claim.
Unnecessary claim denials can be avoided if your office has a clear understanding of these systems and what they will reject.
ClaimCheck
ClaimCheck is a tool that evaluates professional billing for CPT code combination appropriateness.
Strictly following CPT coding guidelines will help eliminate claim rejects. You can avoid claim line rejects by assigning primary and supporting codes that denote the reason for the procedure, as well as any diagnosis that affects treatment.
Some of the ClaimCheck edits are:
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Procedure unbundling
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Incidental procedure
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Mutually exclusive procedure
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Assistant surgeon requirements
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Age conflicts
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Gender conflicts
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Unlisted procedures
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Duplicate and bilateral procedures
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Preoperative (preop) and postoperative (postop) surgical allowances
Any edits that ClaimCheck makes will be explained in a message code on the remittance. Humana Military updates ClaimCheck annually with new coding based on current industry standards.
Be aware that the government contract does not allow providers to bill TRICARE beneficiaries for amounts considered by ClaimCheck to be unbundled or incidental.
TRICARE does not use ClaimCheck to review claims for pharmacy, physical therapy or inpatient institutional stays.
ClaimReview
ClaimReview is an automated module in ClaimCheck that considers the relationship between the submitted diagnosis and the procedures.
To avoid unnecessary claim line rejects, be careful to assign a diagnosis code that represents the reason the procedure is performed and provide information on any diagnosis that would affect the treatment.
ClaimCheck/ClaimReview Rejections
If you receive a ClaimCheck or ClaimReview rejection, you should review your medical documentation for any additional appropriate diagnosis and submit it on a “corrected claim.”
After such review, if other diagnoses cannot be found, a reconsideration can be requested by sending supporting medical record information to the TRICARE South Correspondence address (below). When submitting a ClaimCheck/ClaimReview rejected claim for reconsideration, follow the process outlined on the back of the remittance.
If you have questions about claims edits, contact PGBA at 1-800-403-3950.
TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032
HA9—INVALID REND PHYSICIAN SSN
A common reason for rejected claims, this error message is returned when PGBA, LLC, the claims processor for the South Region, does not recognize the number submitted for Rendering Physician ID. The Rendering Physician ID is typically the SSN of the physician who rendered the service.
If you are located in Texas, Oklahoma, Arkansas, or the western half of Louisiana, you may have previously been sending a 4-digit alphanumeric “sub-ID” to the processor that had the contract prior to Nov. 1, 2004. Now that you are sending your TRICARE claims to PGBA, you need to send the rendering physician’s SSN in the Rendering Physician ID field.
For assistance with this error, or any other issues related to electronic media claims (EMC) submission for the TRICARE South Region, you can contact the PGBA EMC Help Desk at 1-800-325-5920, option 2. You may also visit either www.humana-military.com or www.mytricare.com for more information regarding electronic claims submission.
Remember, TRICARE requires all network providers to file claims electronically.
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