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Nationwide Claims Processing Established for Dual-Eligible Beneficiaries (Article 12)

As part of the next generation of TRICARE contracts, the TRICARE Management Activity (TMA) selected a single contractor, Wisconsin Physicians Service (WPS) to handle claims processing and provide related customer and administrative services for about 1.7 million
dual-eligible beneficiaries—those eligible for both Medicare and TRICARE—in the United States, U.S. Virgin Islands, Puerto Rico, Guam, American Samoa and the Northern Mariana Islands.

WPS is implementing this program for dual-eligibles under the title “WPS TRICARE For Life (WPS TFL).”

If you currently submit claims on a patient’s behalf to Medicare, then you no longer need to submit an additional claim to TRICARE (which acts as second payer after Medicare) for payment.

WPS signed agreements with each state’s Medicare carrier, which allows Medicare to pay its portion and then submit claims directly to WPS TFL for processing. WPS TFL then sends its payment for the remaining beneficiary liability directly to you.

If a beneficiary has other health insurance (OHI), then Medicare pays first and forwards the claim to the OHI, which
pays second. In these instances, the beneficiary must file a paper claim (DD Form 2642— also available online at www.tricare.osd.mil/claims) with WPS TRICARE For Life (P.O. Box 7890, Madison, WI 53707-7890).

Paper claims also must be submitted to WPS TFL if you do not participate in Medicare, or if the services you’ve provided are not Medicare-covered benefits.

Because TFL claims processing is being transitioned over eight months, outgoing regional claims processors will
continue to process claims for services that your dual-eligible beneficiaries receive until WPS TFL has been
implemented in your state (see WPS TFL Rollout Schedule).