We understand that you may be experiencing challenges with claim submissions. We acknowledge that our usual processing times have been delayed due to a major system transition. We are actively working to expedite resolutions and anticipate returning to our standard turnaround times within the next several weeks. For immediate questions or concerns, please reach out to your local Provider Representative.
Humana Military is actively processing claims while we are implementing the following quarterly reimbursement updates. During this process, some claims status will be temporarily set to pending, and claims payments will resume once the implementation is complete. See which claims categories are affected.
For claims with 2024 Dates of Service (DOS): EDI Claims payer ID is TREST.
From January 1, 2025, to April 30, 2025, the current payer organization (WPS) will continue to process claims with a 2024 DOS. After April 30, 2025, claims with a 2024 DOS will no longer be accepted via 2024 processes. Beginning May 1, 2025, submit 2024 claims and claims-related documents to XPressClaims through provider self-service or the clearinghouse.
For claims with 2025 Dates of Service (DOS): EDI Claims payer ID is 99727.
The payer ID will need to be placed in the following data elements within your X12 837 claim files:
ISA-08, GS-03, NM1-09 (with 40 qualifier).
For the clearinghouse, new direct submitters must file a trading partner agreement and enrollment form in order to be assigned a mailbox/submitter ID. If your clearinghouse already files claims to PGBA for other lines of business, you need to ensure that the TRICARE EAST payer ID 99727 is made available as an option. If your clearinghouse does not submit to PGBA, providers, vendors or clearinghouses that can create an ANSI X12 electronic file, and have telecommunications capabilities, can upload files to PGBA directly. Batch claims processing is available through our EDI Gateway mailbox system. Providers must file a PGBA EDI Provider Agreement to submit claims electronically. Please contact the PGBA EDI Help Desk at (800) 259-0264, or email EDI.TRICARE@PGBA.com, for assistance with EDI set-up.
All claims must be submitted electronically in order to receive payment for services. 98% of claims must be paid within 30 days and 100% within 90 days. All claims for benefits must be filed no later than one year after the date the services were provided.
Providers who use clearinghouses to process their claims need to enroll via Electronic Data
Interchange (EDI) express enrollment to process claims and set up EFT/ERA.
To enroll in EDI, providers (or groups where applicable):
Providers who do not use a clearinghouse to process their claims can submit claims through provider self-service.
Per TRICARE policy, Humana Military is required to review and implement claim auditing software to ensure correct code processing on claims. As claims process, the coding is compared to the National Correct Coding Initiative Edits available through a third party vendor and will indicate the error rejecting the line of the claim with a reason code or message.
The TRICARE East Region uses a claims auditing tool to review claims on a prepayment basis. This auditing tool is an automated clinical tool that contains specific auditing logic designed to evaluate provider billing for CPT coding appropriateness and to monitor overpayment on professional and outpatient hospital service claims. Humana Military updates the claims auditing tool periodically with new coding based on current industry standards. Follow CPT coding guidelines to prevent claims auditing editing from resulting in claim denials. Claims auditing edits will be explained by a message code on the remittance advice.
The auditing tool also includes, but is not limited to, the following edit categories*:
*The complete set of code edits is proprietary and, as such, cannot be released to the general public.
Providers disputing the reject or denial of services based on auditing can correct and resubmit under "corrected claim" with supporting documentation on a claim-by-claim basis. Please use these guidelines for reconsideration with a corrected claim.
TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service and other programs or plans as identified by the Defense Health Agency (DHA).
If the OHI benefits are exhausted, TRICARE becomes the primary payer, and additional referral/prior authorization requirements may apply. Since OHI status can change at any time, always ask all beneficiaries about OHI, including National Guard and Reserve members and their families.
Beneficiaries may not waive benefits from their primary plan. If the primary plan provides benefits for services, a claim should be filed with the double coverage plan.
Rendering providers MUST be TRICARE-certified for TRICARE to pay up to the TRICARE Maximum Allowable Charge (TMAC) on covered services.
To avoid a delay in claim payment or a recoupment when OHI is uncovered, we recommend asking beneficiaries for all forms of insurance before they are seen at your office or facility. Laws for commercial plans vary by state, so supplying us with all initial information helps to ensure correct and timely processing.
If a beneficiary’s OHI status changes, update patient billing system records to avoid delays in claim payments. The beneficiary is responsible for contacting TRICARE to add, remove or change their OHI by utilizing the TRICARE OHI Questionnaire. If a claim is processed with OHI, and the beneficiary has contacted TRICARE to remove it, the OHI will automatically be added back to the beneficiary's account and the claim will deny causing a delay in payment.
If a provider indicates that there is no OHI, but Humana Military's files indicate otherwise, a signed or verbal notice from the beneficiary will be required to inactivate the OHI record.
In some cases, the TRICARE Summary Payment Voucher/Remit will state, "Payment reduced due to OHI payment," and there may be no payment and no beneficiary liability. The TRICARE cost-share (the amount of cost-share that would have been taken in the absence of primary insurance) is indicated on the TRICARE Summary Payment Voucher/Remit only to document the amount credited to the beneficiary's catastrophic cap.
Dual eligible beneficiaries with OHI
If the beneficiary has OHI as well as Medicare and TRICARE, TRICARE will pay after Medicare and the OHI. Once Medicare and the OHI have processed the claim, the beneficiary should file a TRICARE claim with WPS.
Identify OHI in the claims form
TRICARE beneficiaries who have OHI do not need referrals or prior authorizations for covered services except for those services listed below, which require prior authorization even when OHI coverage exists.
Claims will be rejected if the NPI is not present in the correct location on the claim form or if there is a mismatch between the information in the National Plan and Provider Enumeration System (NPPES) and our claims system (claims for Corporate Service Providers (CSP) are the exceptions).
NPI in wrong location on the claim form
To correct the issue, include the rendering provider NPI in the correct location on the claim form and contact your clearinghouse to ensure they are placing it in the correct location.
Mismatch of information
If there is a mismatch, call NPPES at (800) 465-3203 to update your information. NPPES is used as the resource for validating NPI data, so it is important that providers review their NPPES records for accuracy. The NPPES resourced data will be updated monthly, by the 22nd of each month.
Edits for 837 professional claims
Edits will be applied to 837 professional claims only when:
A billing NPI is submitted in NM109 of the 2010AA Billing Provider Loop, with place of service 11 (office) only if:
Note: The rendering provider NPI will not be required at this time, but the segment must be provided with the rendering provider name.
As a reminder, the billing provider Address Loop 2010 must have a physical address. If the services rendered were not at this address, then the Service Facility Loop 2310C must be submitted. If there is more than one service facility for the claim, then use the Service Facility Loop 2420C.
Error messages on 277CA claims acknowledgment and suggested resolutions
STC*A7:562:85—Invalid billing NPI
Verify the billing provider NPI is valid; if valid, verify it is active on NPPES
STC*A8:562:85—Invalid billing provider relationship
Verify the billing provider is a solo practitioner or an organization
If the billing provider is a member of a group, the group’s information, including NPI, should be in the 2010AA; and rendering provider information in 2310B or 2420A
If you are a solo practitioner, update your NPPES record
STC*A8:562:82—Invalid rendering provider relationship
Verify that the rendering provider NPI is present
Rendering provider is required for taxonomy codes multi-specialty—193200000X and single specialty —193400000X
STC*A7:562:82—Verify the rendering provider NPI is valid
If valid, verify it is active on NPPES
*Claims may have previously pended and processed (including payment)
National Provider identifiers (NPI) and NPI matching logic
All covered entities are required to use their NPIs on HIPAA-standard electronic transactions in accordance with HIPAA Transaction Electronic Data Interchange for Health Care Providers Implementation Guide.
The NPI billed on the claim will determine where payment, recoupment and remittances will be sent. All payments, recoupments and remittances will process to the Pay-to address or EFT bank account associated with the Primary NPI location. All payments, recoupments and remittances for subordinate locations with the same NPI will roll up to the Primary NPI Pay-to or EFT bank account.
If a separate payment address is needed, that separate payment address will require a separate NPI. When applicable rendering NPIs are also required.
**Note all claims for ABA services must be filed electronically and must include the rendering NPI.
