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  Humana Military, PGBA Offer Claims Processing Resources (Article 6)
  Humana Military and PGBA want to help all TRICARE providers have a better understanding of claims processing procedures. To reach that goal, we’ve developed the following resources:

Live Provider Seminars
Humana Military and PGBA plan to offer claims processing seminars this spring. The seminars will explain how claims processing works and how providers can facilitate the process. Your provider representative will invite you to a seminar or you can check the schedule in the Online Provider Services.
Web Sites
You can obtain the latest information about claims processing, check the status of claims and more, also in the Online Provider Services section. Registered users of either the Humana site or the PGBA Web site can also submit claims electronically.

IVR System
When calling is more convenient, you can use Humana Military’s interactive voice response (IVR) system by calling 1-800-444-5445, or you can call PGBA at 1-800-403-3950 and speak to a provider representative to check on the status of claims, confirm the eligibility of a beneficiary, get an explanation of benefits and obtain pricing.

Remit Forms
Another way to ensure a smooth claims processing experience is to review all provider remits closely. The remit form is now easier to read, and it explains how to get a claim reconsidered satisfactorily.

Claim Check
During claims processing, PGBA uses the ClaimCheck® system to review claims and ClaimReview®, an automated module in ClaimCheck, to check for inconsistencies with TRICARE-covered services. For example, the system will compare the procedure code with the diagnosis code. If the codes are inappropriate for each other, the claim will be denied and the remit will say, “Diagnosis Code and Procedure Code combination non-specific or unrelated.”

To avoid such denials, and improve claims submission accuracy, your staff should review the Claims Processing and Billing chapter of the TRICARE Provider Handbook.

TRICARE Benefits Improve for Reservists and Their Families (Article 7)
The National Defense Authorization Act for 2005 improves the overall health benefits available to guardsmen, reservists and their families, and it makes permanent several of the TRICARE benefits authorized “temporarily” under 2004 defense legislation.

Here is a look at what TRICARE providers need to know:
  • For Reserve Component members with delayed effective date orders to serve on active duty in support of a contingency operation for more than 30 days, the new legislation permanently authorizes TRICARE eligibility for up to 90 days prior to member’s activation date for eligible members and their families.
  • The legislation makes permanent the 180-day transitional period after deactivation in which certain Reserve Component members and their families receive TRICARE health benefits under the Transitional Assistance Management Program (TAMP). Members must now have a comprehensive physical examination within 12 months before the scheduled date of separation from active duty service.
  • The legislation authorizes a waiver of the TRICARE Standard and TRICARE Extra deductibles for Reserve Component family members whose sponsors are ordered to active duty for more than 30 days. Plus, it authorizes TRICARE to pay nonparticipating providers up to 115 percent of the TRICARE maximum allowable charge, enhancing continuity of care for these family members with their civilian providers.
Another provision will enable members of the Reserve Component (those called after Sept. 11, 2001, to serve for more than 30 days in support of a contingency operation, who served or will continuously serve for 90 or more days) to purchase TRICARE Standard health care coverage for themselves and their family members after they demobilize and after their TAMP benefit ends.

The member must sign an agreement to continue serving for a period of one year or more in the selected reserve after their active duty ends. For every 90 days of consecutive active duty service, the member and family members may purchase one year of TRICARE Standard coverage for the same period they commit to serve in the selected reserves.

The option to purchase TRICARE Standard coverage will not be implemented until April 26, 2005.

More information about these changes will be available at and


Alternatives to Hospice Care (Article 8)

Patients who do not elect hospice care have other options. These options, outlined below, must be sought outside of a military treatment facility (MTF) and require prior authorization.

Home Health Care
Covered, Prior Authorization Required
The services covered under TRICARE home health care are the same benefits as those covered under Medicare home health care benefits. They provide a maximum of 28 hours per week part time, or 35 hours per week intermittent, skilled nursing care and physical, speech and occupational therapy. All care must be provided by a participating home health care agency.

Skilled Nursing Care
Covered, Prior Authorization Required
Skilled nursing care typically is not provided in a nursing home or a patient’s home, but rather in a Skilled Nursing Facility (SNF). Under the SNF benefit, TRICARE covers skilled nursing care and rehabilitative (physical, occupational and speech) therapies, room and board, prescribed drugs, laboratory work, supplies, appliances and medical equipment.

For TRICARE to cover a patient’s admission to an SNF, the patient must have had a qualifying medical condition that was treated in a hospital for at least three consecutive days. Admission to the SNF is covered as long as the patient is admitted within 30 days of his or her discharge from the hospital (with some exceptions for medical reasons). You will need to demonstrate the patient’s need for skilled nursing services for TRICARE to pay for the SNF care.

Long-Term Care
Not Covered
Long-term care (LTC), also known as “custodial care,” involves primarily providing an individual assistance with activities of daily living or supervision of someone who is cognitively impaired. Long-term care can be provided in many settings, including nursing homes, assisted living facilities, adult day care or at a patient’s home. Long-term care is not a TRICARE covered benefit.

Room, board and the services mentioned above that are a covered benefit for SNF care are not covered under Medicare or TRICARE if determined to be part of long-term care. Long-term care costs are the patient’s responsibility.

Patients can purchase LTC insurance through commercial insurance programs or the Federal Long Term Care Insurance Program (FLTCIP).

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