Humana Military Healthcare Services TRICARE Provider News Issue 4:2004 Article 1

                                                                                                                                                  Print Full Version

1.     Three Simple Ways to Eliminate Claim Denials
2.     Prime Travel Benefit Offsets Travel Costs to Distant Specialists
3.     XPressClaim Minimizes Errors That Lead to Denials
4.     Contacts

Three Simple Ways to Eliminate Claim Denials (Article 1)

Humana Military and claims contractor PGBA LLC understand that claim denials are frustrating, costly and time-consuming. With that in mind, here are three simple ways to avoid the hassle:

       1. Use the Correct Social Security Number

One of the most common reasons for claims denials is an incorrect Social Security number (SSN) for a patient. Providers and staff should use the TRICARE sponsor’s SSN when filing a claim and not necessarily the patient’s SSN. If the patient is not the sponsor, the patient’s SSN will not be on file and the claim will be rejected.

       2. Assign Primary and Supporting Codes

PGBA uses the ClaimCheck® system to review claims. ClaimCheck edits for inconsistencies with TRICARE covered services. PGBA also uses ClaimReview®, an automated module in ClaimCheck designed to check claims for consistency in specified diagnostic and procedure codes. You can avoid claim line denials by assigning primary and supporting codes that denote the reason for the procedure, as well as any diagnosis that affects treatment.

       3. Apply Accurate Coding

When filing claims, you and your staff should use the current procedural terminology (CPT) or health care procedural coding system (HCPCS) codes that most accurately describe the procedure or service involved. You should not select codes that approximate the service involved, and you should avoid using unlisted or miscellaneous codes. When no code exists, it is likely the procedure or service is not covered. ClaimCheck edits are explained on the remittance advice. You may request verification that the edit was applied correctly by asking for an explanation of ClaimCheck auditing logic. You may also request a medical review to reconsider ClaimCheck edits by writing to:

TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032

After medical review, Humana Military/PGBA may override the ClaimCheck edit and allow an additional amount to be paid. Remember, network providers are not permitted to bill TRICARE beneficiaries for amounts considered unbundled or incidental by ClaimCheck. If you have further questions regarding claims editing, contact PGBA directly at 1-800-403-3950 or visit the PGBA Web site at www.myTRICARE.com.