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TRICARE network providers must file patients’ TRICARE claims, even when a patient has other health insurance, and all claims must be filed electronically. Here are a few tips to improve your claims filing success.

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. You should also avoid using unlisted or miscellaneous codes. When no code exists for the procedure or service, it is likely the procedure or service is not covered.

ClaimCheck Standards
When reviewing claims in the South Region, Humana Military and claims processing partner, PGBA, use ClaimCheck® software, which evaluates claims for coding appropriateness and seeks to eliminate overpayment on professional and outpatient hospital claims.

ClaimCheck is designed to prevent payments from exceeding 100 percent of the TRICARE allowable charge. PGBA updates ClaimCheck annually with new coding based on current industry standards.

To prevent ClaimCheck from denying claims, follow CPT coding guidelines. If ClaimCheck makes any edits, the edits will be explained on the remittance advice. Edit categories include the following:

• Procedure unbundling
• Incidental procedure
• Mutually exclusive procedure
• Assistant surgeon requirements
• Age conflicts
• Gender conflicts
• Alternate code replacements
• Cosmetic procedures
• Unlisted procedures
• Modifier auditing
• Duplicate and bilateral procedures
• Preoperative (preop) and postoperative (postop) auditing billed
• Billed date(s) of service

Not subject to TRICARE ClaimCheck are those claims for pharmacy, physical therapy and inpatient institutional care.

ClaimCheck Appeals
In some cases, you may want a medical review to reconsider ClaimCheck edits. If so, you may request verification that the edit was applied correctly by asking for an explanation of ClaimCheck auditing logic. You also can submit documentation showing that unusual circumstances existed.

When seeking medical review or to provide additional documentation, you should write 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, you are not permitted to bill TRICARE beneficiaries for amounts considered unbundled or incidental by ClaimCheck.

ClaimReview
A module within ClaimCheck, called ClaimReview®, allows PGBA to ensure that the diagnosis and procedure codes match.

To avoid claim line denials, you should assign a diagnosis code that represents the reason why the procedure has been performed and any other diagnosis that would affect the patient’s treatment plan.

If a line on the claim is rejected, you should review the medical documentation for any additional diagnosis, and if found, submit the documentation on a corrected claim. If after review, other diagnoses cannot be found, a reconsideration can be requested by sending supporting medical record information to the address above.

If you have questions regarding claims editing, contact PGBA directly at 1-800-403-3950 or visit the PGBA Web site at www.mytricare.com.