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Provider Handbook
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Other Helpful Hints
HIPAA National Provider Identifier Compliance |
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Other Helpful Hints |
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EMC Help Desk |
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PGBA operates an EMC Help Desk to assist you with any issues related to TRICARE electronic claims submissions. The telephone number is 1-800-325-5920, menu option 2. When you call, be sure to identify yourself as a TRICARE provider. |
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Supporting Documentation |
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TRICARE claims that require hard copy supporting documentation can still be filed electronically. PGBA has a dedicated fax to receive supporting documentation for electronically submitted claims. Use the EMC Attachment Form to ensure that the documentation is correctly matched up to your claim. To obtain a copy of the EMC Attachment Form along with the fax number, call the EMC Help Desk at 1-800-325-5920, menu option 2 or download a copy.
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Claims with Other Health Insurance |
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When filing claims that have OHI with TRICARE as secondary payer, you can avoid having to send a hard copy explanation of benefits (EOB) from the primary payer if you can transmit the required information electronically. PGBA needs to know the amount the primary insurance paid. If the primary insurance is a PPO, HMO, Medicare, or other insurance where there is a limited liability for the patient, then you also need to indicate the OHI allowed amount. The OHI allowed amount represents the amount paid by the primary insurer plus any out-of-pocket expenses owed by the patient. In cases where the primary insurance paid zero, include the reason nothing was paid. |
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HIPAA National Provider Identifier Compliance |
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By May 23, 2008, all covered entities should have obtained their National Provider Identifiers (NPIs) and be prepared to submit their NPIs on Health Insurance Portability and Accountability Act 1996 (HIPAA) standard electronic transactions in accordance with the Implementation Guide. TRICARE, like the majority of other payers, will not deny claims for failure to include the provider's NPI on the HIPAA standard electronic transaction before the compliance date. However, in order to facilitate the use of the NPI as a routine practice for the submission of HIPAA transactions, providers are encouraged to begin using their NPI as their primary provider identifier as soon as possible. Providers treating TRICARE beneficiaries as a result of referrals should also be aware that transactions will continue to be processed if the NPI for the referring provider is not included on the transaction. However, providers are encouraged to obtain the referring provider’s NPI and include it on transactions per the Implementation Guide for each transaction. The NPI should be provided if appropriate per the Implementation Guide for the transaction. |
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EMC Response Reports |
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To ensure that your electronic TRICARE claims are accepted by PGBA’s system for processing, it is imperative that you reconcile your EMC transmissions with the EMC response reports returned by PGBA for every transmission. These responses show the claims that were rejected as well as the claims that were accepted for processing. Review these responses to ensure that EMC transmissions are not lost and to identify rejected claims so you can correct and resubmit them electronically for processing. If your TRICARE claims are submitted through a clearinghouse or other vendor, the PGBA responses are returned to that entity. Note that many clearinghouses perform their own edits and create their own reports which show how many claims were received from the provider and forwarded on to the payer, but only the PGBA responses show you which claims were received and accepted by PGBA for processing. If you are not sure if you are receiving these PGBA EMC responses, contact your vendor or the PGBA EMC Help Desk at 1-800-325-5920, menu option 2. |
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