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          Humana Military Partners with PGBA for Claims Processing (Article 4)
  Humana Military Healthcare Services partnered with PGBA, LLC of South Carolina to serve as claims processor for the TRICARE South Region.

Providers who have worked with PGBA in the past and who are already registered to submit electronic claims on www.myTRICARE.com can continue to use their existing password and submit claims the way they always have.

 
Claims Submission Transition
Network providers in the South Region are required to submit claims electronically.

Paper claims from non-network providers and other claims correspondence should be sent to the following South Region address:
          TRICARE South Region
          Claims Department
          P.O. Box 7031
          Camden, SC 29020-7031

For health care services you provided prior to your area’s transition date, you can continue submitting claims as you always have. Claims submission transition information is as follows:
  • Providers in former Regions 3 and 4 (Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee and the New Orleans area of Louisiana) should continue to submit claims to Humana Military/PGBA.
  • Providers in former Region 6 (Arkansas, Louisiana, Texas (excluding the extreme western El Paso area) and Oklahoma) should submit claims to Health Net Federal Services/WPS for services before Nov. 1, 2004. For services on or after Nov. 1, 2004, you should submit claims to Humana Military/PGBA.

See “Humana Military and PGBA Offer Four Electronic Claims Submission Options,” page 5, for more details on submitting claims to Humana Military/PGBA.

Claims Processing Timelines
All TRICARE South Region claims must be submitted to Humana Military/PGBA for payment within one year of the date the service was rendered or according to the provider contract.

You can check the status of claims by visiting the Online Provider Services. You may also call the PGBA voice response system at 1-800-403-3950.  Click here to register for Online Provider Services.

 

Tips for Avoiding Denied Claims 

Unnecessary claim denials are time consuming and costly
for everyone involved. Here’s an at-a-glance look at a few
ways you can ensure timely claims processing.

ClaimReview
Humana Military also utilizes ClaimReview®, an automated module in ClaimCheck designed to check claims for consistency in specified diagnostic and procedure codes.

ClaimCheck
The TRICARE South Region uses the ClaimCheck® system to review claims on a prepayment basis. As you complete a claim form, ClaimCheck edits for:

To avoid claim line denials, make sure to assign primary and supporting codes that denote the reason for the procedure, as well as any diagnosis that impacts treatment.
  • Procedure unbundling
  • Incidental procedures
  • Mutually exclusive procedures
  • Assistant surgeon requirements
  • Age and gender conflicts
  • Alternate code replacements
  • Unlisted or cosmetic procedures
  • Modifier auditing
  • Other inconsistencies with the contract

Should a claim be rejected because of an inaccurate or insufficient diagnosis code, submit a corrected claim with the complete and accurate diagnoses and any supporting medical documentation needed.

If you have any questions regarding this editing function, contact PGBA at 1-800-403-3950.

Edits may be reconsidered through medical review. To request a medical review, write and submit additional documentation to:   
          TRICARE South Correspondence
          P.O. Box 7032
          Camden, SC 29020-7032

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