• TRICARE pays after a beneficiary’s other health insurance (OHI), including Medicare, employment-based coverage, and other insurance policies and plans.
• If the OHI denies a claim because the beneficiary did not follow the OHI’s rules, TRICARE will also not pay.
• Prior authorization is required for those services previously listed that will be billed to TRICARE, even when the beneficiary has OHI.

HIPAA Transaction Standards and Code Sets

The Health Insurance Portability and Accounting Act of 1996 (HIPAA) Transaction Standards and Code Sets regulations allow health care providers to electronically verify patient eligibility; request authorizations and referrals; submit claims; and check claims and request status. All health care providers, plans, and clearinghouses are required to comply and must use the following standard formats for TRICARE behavioral health care claims:

• 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 HIPAA standards. To avoid future cash-flow disruptions, all providers must convert to HIPAA-compliant claims formats. For more information on HIPAA Transaction Standards and Code Sets, see the Important Provider Information section of this handbook or visit the PGBA web site.  
        

Behavioral Health Care Claim Tips

• File claims with PGBA within one year of the date of service or one year from the day of discharge for an inpatient admission.
• Behavioral health care includes the ICD-9 diagnosis range 290.0–314.9. Only physicians and other licensed or certified behavioral health care providers may bill for psychiatric CPT codes or ICD-9 diagnoses.
• Balance billing a beneficiary is not permitted, unless a beneficiary requests and obtains approval of a waiver.
• File hospital and other institutional care claims on UB-04 forms.
• File professional services claims on CMS-1500 forms.
• Professional providers must use CPT codes to bill for services.
• Facilities must use revenue and HCPCS codes (if required) to bill for services.
• Properly inform beneficiaries in advance if services are not covered. You are financially responsible for any non-covered services you provide to a TRICARE beneficiary who was not properly informed in advance of non-coverage and/or who did not agree in advance and in writing to pay for the non-covered services.  See the Important Provider Information section of this handbook for more information.
• Visit MyHMHS for Providers, or call PGBA at 1-800-403-3950 to check claims status. Claim check services are available 24 hours a day, seven days a week.
• If ValueOptions denies a claim because you did not obtain required authorization, follow instructions on the remittance statement or call ValueOptions at 1-800-700-8646 for assistance.
  

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