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.
Supporting Documentation
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.
Claims with Other Health Insurance
When filing claims that have other health insurance (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 preferred provider organization (PPO), health maintenance organization (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.
EMC Response Reports
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 that 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.
Common EMC Rejects
HIPAA National Provider Identifier Compliance
Effective May 23, 2008, all covered entities must use their National Provider Identifiers (NPIs) and submit NPIs on HIPAA standard electronic transactions in accordance with the Implementation Guide. When filing claims with NPI(s), billing NPIs are always required and rendering provider NPIs, when applicable, are also required. Providers treating TRICARE beneficiaries as a result of referrals should also obtain the referring provider’s NPI and include it on transactions, if available, per the Implementation Guide for the transaction. See the
Important Provider Information section of this handbook for additional details on HIPAA NPI compliance.
HIPAA Transaction Standards and Code Sets
For your TRICARE claims, the following HIPAA standard formats must be used:
- ASC X12N 837—Health Care Claim: Professional, Version 4010 and Addenda
- ASC X12N 837—Health Care Claim: Institutional, Version 4010 and Addenda
TRICARE contractors and other health care payers are prohibited from accepting or issuing transactions that do not meet the standards. In order to avoid cash flow disruptions, it is imperative that you use the HIPAA-compliant claims formats.
If you need any assistance with HIPAA standard formats for TRICARE, you may call the PGBA EMC Help Desk.
Filing Paper Claims
When filing a paper claim, make sure that you complete the CMS-1500 or UB-04 accurately and fully. Submit the paper claims to:
TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC 29020-7031
The most appropriate Current Procedural Terminology (CPT®) code must be used when billing TRICARE—do not unbundle charges into separate CPT codes when a single code is more appropriate. If the CPT code you are billing does not match the services authorized, the claim will be denied. Institutional providers billing with certain revenue codes require submission of Level II Healthcare Common Procedure Coding System (HCPCS) codes for description of services and supplies.
The signature of the provider, or an acceptable facsimile, is required on all claims, including the UB-04 institutional claim form. In lieu of the provider’s actual signature, a facsimile signature or signature of a representative will be accepted if TRICARE has the proper authorization forms on file. Claims submitted without the proper signature will be returned or denied.
Note: The signature of non-network providers, or an acceptable facsimile, is required on all non-network claims in accordance with Chapter 8, Section 4 of the TRICARE Operations Manual. If a non-network claim does not contain an acceptable signature, the claim will be returned. Because the provider’s signature block Form Locator (FL) was eliminated from the UB-04, the National Uniform Billing Committee has designated FL 80 (Remarks), as the location for the non-network provider signature if signature-on-file requirements do not apply to the claim. The TRICARE South Region has implemented a signature-on-file capability for non-network providers. Contact PGBA for details. To ensure TRICARE has the appropriate signature authorization forms on file, refer to the TRICARE Operations Manual, Chapter 8, Section 4.
Checking the Status of Your Claims
To check the status of your claims, visit “
MyHMHS for Providers.” You may also call the PGBA voice response system at
1-800-403-3950. The line is available 24 hours a day, seven days a week. To check on the status of a claim in writing or to resubmit a claim, direct your correspondence to:
TRICARE South Region
Customer Service Dept.
P.O. Box 7032
Camden, SC 29020-7032
Tracer Claims
When resubmitting an unchanged claim, write “Tracer” across the top of the claim form.
Corrected Claims
When submitting a correction to those claims previously accepted by PGBA for processing, the claims must be flagged as corrected claims. For details about how to submit corrected claims electronically, refer to the
PGBA HIPAA Companion Guides for 837 claims. If submitting a corrected claim on paper, write “Corrected” across the top of the claim form and resubmit the form.
Timely Filing
All TRICARE provider claims must be submitted to PGBA for payment within one year of the date the service was rendered or according to the provider contract.
Returning Incorrect Payments
If you receive a duplicate or overpayment for a claim for TRICARE beneficiaries, TRICARE requests that this payment be returned to TRICARE Finance.
Duplicate payments for TRICARE For Life (TFL) claims should be returned to Wisconsin Physicians Service (WPS) —TRICARE For Life. Please include a copy of the remittance advice and a cover letter explaining exactly why the money is being returned.
If a remittance advice is not included, please provide information about the beneficiary and the claim (including the recoupment case number) to help ensure that the refund is credited to the correct claim.
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| Return duplicate payments or overpayment (except TFL) to: |
PGBA
Attn: TRICARE Finance
TRICARE Refunds/AG900 PGBA
P.O. Box 100279
Columbia, SC 29202-3279 |
Return TFL duplicate payments or overpayment to: |
Wisconsin Physicians Service
Attn: TDEFIC
P.O. Box 77028
Madison, WI 53707-1028 |
If you do not return the overpayment, then PGBA may, after written notice, offset the amount of double payment against future claim payments.
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