Provider Handbook

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• Behavioral health care includes the ICD-9 diagnosis range 290.0–314.9.
• Only physicians and other providers licensed or certified as behavioral health care clinicians may bill for psychiatric CPT codes or ICD-9 diagnoses.
• Only one initial evaluation (CPT Code 90801–90802) should be billed unless a second evaluation has received prior authorization.
• Network providers must file TRICARE patient claims, even when the patient has  OHI.
• Hospital and other institutional claims must be filed on a UB-04.
• The CMS-1500 form is used for filing claims for professional services.
• TRICARE is secondary to private insurance policies or coverage provided through the beneficiary’s place of employment.
• Amounts which have been denied by the other coverage simply because the claim was not filed in a timely manner (with the other coverage) or because the beneficiary failed to meet some other requirements of coverage cannot be paid.
• Prior authorization is required for those services, previously listed, that will be billed to TRICARE, even when the beneficiary has OHI.
• Professional providers use CPT codes and facilities use revenue and HCPCS codes (if required) to bill for services).
• Balance billing a beneficiary is not permitted.
• Providers should note that beneficiaries must agree in advance of any non-covered service procedure, in writing, to be responsible for any specified non-covered services. The patient is “held harmless” in cases of non-covered services provided by a network provider without specific, advance written agreement by the patient for each non-covered service. A general waiver does not meet this requirement.
• TRICARE provider claim-filing limits require claims to be submitted to PGBA for payment within one year from the date of service rendered.
• To check claims status visit Online Provider Services, or call PGBA at 1-800-403-3950. These services are available 24 hours a day, seven days a week.
• TRICARE supplemental insurance policies do not qualify as OHI. When only a supplemental policy is involved, file the TRICARE claim first.
• Providers should contact PGBA directly with questions or for assistance regarding claims they can access the PGBA Web site.

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