• TRICARE network providers must file all claims electronically (See “Electronic Claims Submission” later in this section) within 90 days of the date care was provided.
• Where TRICARE is the secondary payer, the 90-day claims-filing period will commence once the primary payer has made payment or denied the claim.
• During a TRICARE program phase-out period (end of one TRICARE contract and start of a new one), network providers must use their best efforts to submit TRICARE claims within 30 days from the date services are rendered or the date of the primary payer’s explanation of benefits (EOB).

Important Billing Tips

There are several reasons why claims are delayed or denied unnecessarily. Here are some helpful billing tips to help facilitate prompt claims payments. Industry standard modifiers and condition codes may be billed on outpatient hospital or individual professional claims to further define the procedure code or indicate that certain reimbursement situations may apply to the billing.

• Provider identification number and address: All claims may include the provider’s federal Tax Identification Number (TIN) and the unique three-digit suffix assigned by Humana Military in Box 25 of the CMS-1500 claim form; the provider’s physical address, including ZIP code, in Box 32; and the provider’s pay-to address and ZIP code in Box 33. On the UB-04 institutional claim form, enter the physical address of the facility in the Form Locator (FL) 1 field and enter the pay-to address in the FL 2 field. The facility’s federal TIN is entered in the FL 5 field.
• NPIs: Include all applicable NPIs.
• Provider signature: Always include the provider’s signature or use a signature stamp in Box 31 of the CMS-1500 claim form. The signature stamp must be on file with Humana Military and PGBA. “Signature on File” is an acceptable signature on electronic claims only. Because the provider’s signature block FL was eliminated from the UB-04 institutional claim, the National Uniform Billing Committee has designated FL 80 (Remarks) as the location for the provider signature if signature-on-file requirements do not apply to the claim. Note: All non-network claims must have a provider’s signature, or an acceptable facsimile, in accordance with the TRICARE Operations Manual, Chapter 8, Section 4. If a non-network claim does not contain an acceptable signature, the claim will be returned.
• Demographic changes: You must inform Humana Military of any changes that occur in professional affiliation, TIN, office location, or telephone number. Call 1-800-444-5445 or visit the MyHMHS for Providers portal to update your information. Additionally, Humana Military will contact network providers periodically to verify provider demographic information, panel status, and their ability to meet office appointment and access standards.
• Prior authorization: Certain services require a prior authorization from Humana Military. Enter the prior authorization number in Box 23 of the CMS-1500 claim form or FL 63 of the UB-04 claim form. Note: Network provider claims submitted for services rendered without a required prior authorization are subject to a 10 percent penalty of the negotiated rate.
• Additional prior authorization: If you provide additional services beyond what has been covered by the initial prior authorization, you must notify Humana Military to ensure correct claims payment.
• XPressClaim®: XPressClaim is a fast, easy, and free real-time online claims processing system available through MyHMHS for Providers and the PGBA web site. You also can reconcile claims payments, check claim status, and check OHI information through online claims tools available on these Web sites.
• “Clean Claims”: Most “clean claims” (claims that comply with billing guidelines and requirements, have no defects or improprieties, include substantiating documentation when applicable, and do not require special processing that would prevent timely payment) will be processed within 30 calendar days. Generally, claims aged more than 30 days will be paid interest in addition to the payable amount.
• Claims status: You can check the status of submitted claims online or the PGBA web site, or by calling 1-800-444-5445.
• Tracer claims: When resubmitting an unchanged claim, write “Tracer” across the top of the claim form.
• Timely submission: 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.
• Claim corrections: When submitting a correction to 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 on the PGBA web site. If submitting a corrected claim on paper, write “Corrected” across the top of the claim form and resubmit the form.
• Services provided on behalf of another provider: Always clearly indicate “On Call” in a prominent place on the CMS-1500 claim form for services performed on behalf of another provider. If submitting paper claims, do not use red ink stamps.
• Beneficiary signature: Always include the TRICARE beneficiary’s signature in Boxes 12 and 13 of the CMS-1500 claim form; alternatively, you may indicate “patient not present” if the beneficiary’s signature is on file. For laboratory claims for venipuncture with a place of service of 81, either the patient’s signature or “Signature on File” is required. For other laboratory and X-ray services, you may indicate “patient not present for services.” The beneficiary’s signature is not required. Also include the TRICARE sponsor’s Social Security number (SSN) in Box 1 of the CMS-1500 claim form or FL 60 of the UB-04 claim form.
• Admitting diagnosis: The admitting diagnosis is required on all UB-04 inpatient claims.
• Itemization/breakdown of charges: Complete Section 24, Columns A–J (e.g., place of service, charges in Column F, date of service) of the CMS-1500 claim form to ensure proper itemization of charges.
• Place of service codes: Use the correct place of service codes. (See Box 24B of the CMS-1500 claim form.)
• OHI: Always ask the patient if he or she has OHI. It is your responsibility to submit OHI benefit information in Boxes 4, 9, 11, and 29 on the CMS-1500 claim form or FL 39, 50, 54, and 58 of the UB-04 claim form, or submit an EOB statement from the OHI carrier with the TRICARE claim if submitting a paper claim. For EDI billing instructions, please visit PGBA's web site. Note: You may not bill the beneficiary for cost-shares or copayments when the OHI has paid more than the contractual TRICARE-allowable charge.
• Unlisted or unspecific current procedural terminology (CPT®) codes: When submitting a paper claim and billing with an unlisted or unspecified CPT procedure code, you must include supporting documentation describing the services rendered or the claim will be returned for this information. For electronic claims, include the codes and PGBA will request additional information from you separately when applicable.
• Third-Party Liability (TPL): If billing for care that may involve TPL (diagnosis codes 800–999), instruct the beneficiary to promptly respond to any request for TPL information. Once the beneficiary returns the signed TPL Statement of Personal Injury—Possible Third Party Liability (DD Form 2527) form to Humana Military, the claim will be processed.
• ICD-9/DSM-IV codes: When billing ICD-9 diagnosis codes, code services to the highest level of specificity (e.g., five-digit level). DSM-IV codes are required for behavioral health conditions.
• Services that require specific units of service: When billing for these services, such as allergy testing and treatment, code units of service based on the description in the most current edition of the CPT publication.
• Out-of-region claims: Submit claims to the TRICARE region where the beneficiary resides and/or is enrolled. Refer to “Processing Claims for Out-of-Region Care” later in this section.
• Beneficiaries eligible for Medicare and TRICARE: For beneficiaries who are eligible for Medicare and TRICARE, submit Medicare claims first. Claims will automatically be transmitted from Medicare to TRICARE for secondary claims processing, and Wisconsin Physicians Service/TRICARE For Life (WPS/TFL) will process the TRICARE portion of the claim. Refer to “Claims for Beneficiaries Using Medicare and TRICARE” later in this section for more information.
• Maternity antepartum care: Submit claims with the appropriate level of service codes. Refer to the current edition of the CPT publication.
• Physician assistants/nurse practitioners: When billing for a physician assistant or any other rendering provider (other than the individual provider shown in Box 33 of the claim form), you must include the provider’s name, SSN, or NPI in Column 24 of the CMS-1500 claim form.
• Laser surgery: Submit claims for laser surgery with a laser-specific CPT code for appropriate reimbursement. Without the laser surgery code, the claim will be reimbursed as a conventional surgical procedure.
• Injectables: For injectables administered in the office, bill the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the injectable being administered. When billing for a drug for which there is no defined allowable in the Medicare “J” Code Pricing File, provide the appropriate HCPCS code and the applicable National Drug Code (NDC) printed on the manufacturer’s drug packaging label (use 11-digit format) in Column 24D of the CMS-1500 claim form.  Ensure that the appropriate units are indicated in Column 24G of the CMS-1500 claim form.
• Active duty service member (ADSM) claims: Send TRICARE Prime Remote (TPR) and Supplemental Health Care (SHCP) claims to PGBA for processing and payment. There are no copayments, cost-shares, or deductibles for ADSMs. Note: ADSM claims will be paid at the same negotiated rate as stated in your contracted agreement. There are no copayments, cost-shares, or deductibles for ADSMs or active duty family members (ADFMs) enrolled in TPR. For ADFMs, the copayment, cost-share, and deductible waiver does not apply to pharmacy copayments, the TRICARE Extended Care Health Option (ECHO) cost-shares, or point-of-service (POS) cost-shares and deductibles. The same balance billing limitations applicable to TRICARE apply to the SHCP. For more information regarding balance billing, see the Important Provider Information section of this handbook.
• Anesthesia claims: Claim submissions must include the five-digit CPT-4 anesthesia code, start and stop times, and the appropriate anesthesia modifier. Claims submitted with surgical codes will be denied.

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