Filing Electronic Claims

• Improved cash flow—On average, TRICARE electronic claims are processed two to three weeks faster than paper claims. This, combined with the elimination of mail time, means that you will receive your TRICARE payments much faster if you file your TRICARE claims electronically.
• Reduced postage and paper-handling costs
• Elimination of data entry errors
• Better audit trail—Electronic media claims (EMC) response reports show you which claims were accepted for processing. Also, front-end EMC edits give you prompt feedback regarding problems with your claims, allowing you to correct and resubmit them more quickly.
• Real-time claims processing—If you are using XPressClaim^TM (see “Electronic Claims Filing Options”), you can submit your claims online and instantly find out how much TRICARE will pay.
• Electronic remittance advice (ERA) and electronic funds transfer (EFT)—Network providers who file all of their TRICARE claims electronically are eligible to receive ERAs and EFTs.

Humana Military offers innovative solutions that allow you to file your claims electronically, making filing TRICARE EMC easier.

Electronic Claim Filing Options

There are several options for filing your claims electronically.

XPressClaim on myTRICARE.com

With XPressClaim, you can submit secure TRICARE CMS-1500 and UB-04 claims and receive instant payment results. You can also print a patient summary receipt while your patient is still in the office. There is no cost to use XPressClaim. To sign up, visit PGBA and look for XPressClaim under the Provider section.

eZ TRICARE Claims

With eZ TRICARE Claims you can upload batches of claims directly from your practice management system. There is no software to install, no data entry, and no cost to file your TRICARE claims. eZ TRICARE Claims can accept a variety of claims formats, including National Standard Format (NSF), ASC X12 837, and CMS-1500 or UB-04 print files. To sign up for eZ TRICARE Claims, visit MyHMHS for Providers.

Clearinghouses

Humana Military receives TRICARE claims from a large number of EMC clearinghouses. You should contact your clearinghouse in order to find out what you need to do to send your TRICARE claims to Humana Military. Depending on the clearinghouse, Humana Military may be listed in payer listings as Humana Military Healthcare Services, PGBA (our claims processing partner), or TRICARE South.

Electronic Data Interchange Gateway

If your system can create HIPAA-compliant claims formats and you prefer to send your claims directly to the payer, then PGBA’s Electronic Data Interchange (EDI) Gateway may be right for you. PGBA built the EDI Gateway to handle all of their inbound and outbound HIPAA-compliant EDI transactions. The communications protocols supported are Asynchronous Dial-up, File Transfer Protocol (FTP), and CONNECT: Direct/NDM. To enroll or learn more about the EDI Gateway, contact the EMC Help Desk at 1-800-325-5920, menu option 2.

Network providers submitting claims and conducting other transactions through EDI agree to the following provisions constituting a trading partner agreement in order to comply with Chapter 21, Section 3 of the TRICARE Operations Manual:

1. The provider should not disclose any protected health information concerning a TRICARE beneficiary to any third party except Humana Military, its claims processing subcontractor (“Claims Processor”), or the TRICARE Management Activity (TMA), without the written consent of the TRICARE beneficiary or his or her authorized representative, or where disclosure is necessary for the care and treatment of the beneficiary, for the purpose of payment for the services provided by the provider, or as otherwise authorized or required by state or federal law.
2. The provider should submit claims only on behalf of those TRICARE beneficiaries who have given their written authorization, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file with the provider. For eligibility transactions, eligibility does not indicate authorization for services.
3. The provider should ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect all of the following information:
   • Beneficiary’s name
   • Beneficiary’s health insurance claim number
   • Date(s) of service
   • Diagnosis/nature of illness
   • Procedure/service performed
4. The provider agrees that TMA, or its designee, has the right to audit and confirm information submitted by the provider and will have access to all original source documents and medical records related to the provider’s submissions, including the beneficiary’s authorization. All incorrect payments that are discovered as a result of such an audit will be adjusted according to the applicable provisions of the TRICARE program regulations, policies, and guidelines.
5. The provider should retain all original source documentation and medical records pertaining to any such particular TRICARE claim for a period of at least seven years after the claim is processed.
6. The provider should affix his or her unique identifier number, assigned by the claims processor, on each claim electronically transmitted to the contractor.
7. The provider agrees that each and every claim submitted electronically, for all legal and other purposes, will be considered signed by the provider or the provider’s authorized representative.
8. The provider should implement sufficient security procedures to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access by third parties.
9. The provider acknowledges that all claims for services provided to TRICARE beneficiaries are paid from federal funds, and that the submission of such claims is a claim for payment under the TRICARE program.
10. The provider will notify the claims processor within two business days if any transmitted data are received in an unintelligible or garbled form.
11. Transmission Format: All standard transactions, as defined by Social Security Act Section 1173(a) and the Transaction and Code Sets Final Rules, conducted between Humana Military or the claims processor and the provider or any business associate, will only use code sets, data elements, and formats specified by the Transaction and Code Sets Final Rules and the then current version of the Claims Processor’s Supplemental Implementation Guides. The Claims Processor’s Supplemental Implementation Guides and any updates or amendments thereto may be accessed at PGBA's Web site, and are incorporated herein by reference. This section will automatically amend to comply with any final regulation or amendment to a final regulation adopted by U.S. Department of Health and Human Services (HHS) concerning the subject matter of this section upon the effective date of the final regulation or amendment.

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