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Electronic claims processes

Humana Military was awarded the new East Region contract for TRICARE with an effective date of January 1, 2018. Wisconsin Physicians Service (WPS) will be the new fiscal intermediary/claims processor for TRICARE in the new East Region. The new East Region is a merger of the existing TRICARE North and TRICARE South Regions, which includes the following states: Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa (Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St. Louis area), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas (excluding El Paso area), Vermont, Virginia, West Virginia and Wisconsin.

View region map

The transition of provider electronic claims processes, including Electronic Media Claims (EMC), Electronic Funds Transfers (EFT) and Electronic Remittance Advice (ERA), to WPS for the new East Region, has been completed to ensure all providers were ready for the start of healthcare delivery on January 1, 2018. Providers are expected to enroll anew for EMC, ERA, and EFT through WPS. Electronic interface with the current fiscal intermediary/claims processor will not transfer.

Jointly, Humana Military and WPS will make every effort to assist providers in a smooth transition of claims processing. The following is a full explanation of the provider registration process for EDI/EMC.


Alternate online claims entry portal

The Humana Military secure provider portal offers an online claims entry option that will allow TRICARE East providers to enter and submit claims. More information will be provided when the online option becomes available.


EDI set-up with WPS

WPS requires that all electronic providers/groups sign, and have on file, a Trading Partner Claims Agreement (“Agreement”) prior to submission of electronic claims.

All providers that will submit EDI claims directly to WPS will need to complete a self-registration process that includes an initial registration and the necessary request forms and business agreement(s).

Begin the registration process

**NOTE: if you experience system access issues and WPS Community Manager pages do not load correctly, please ensure that your ISP or network service vendor does not have firewall policies that block the following ports by default:

  • 16811 for Community Manager registration and self-service
  • 16705 for 1-way SOAP (real-time) authentication
  • 16707 for 2-way SOAP (real-time) authentication
  • 22 for SSHFTP file transfer

Browser compatibility: While WPS Community Manager supports various web browsers, it has been our experience that using Internet Explorer (IE) may not provide a full level of performance for this application. We have experienced better performance using browsers such as Chrome, Firefox and Safari. We suggest you try using several different browsers to find the highest level of performance.

 

Request form and business agreement overview

Depending on your submitter type, you will need to complete request forms and business agreements after you have registered. They include:

  • Trading partner/submitter ID enrollment information form
  • Connectivity agreement (Required for ALL trading partners)
  • Clearinghouse agreement (Required ONLY for clearinghouses)
  • Line of Business/Transaction (LOB/TXN) configuration edit form (used to setup the various lines of business and types of transactions each trading partner will be utilizing)
  • A separate LOB/TXN Configuration Edit Form is required for each line of business and transaction combination
  • Provider EDI Registration
  • Provider agreement (a separate agreement is required if registering for both Medicare and non-Medicare lines of business)
  • Provider Electronic Remittance Advice (ERA) Agreement (optional)
  • Provider Electronic Funds Transfer (EFT) Agreement (optional)
  • Line of Business/Transaction (LOB/TXN) Production Approval Form (to be completed by direct submitters once a successful test file has been submitted)
  • A separate LOB/TXN Production Approval Form is required for each line of business and transaction combination

Please note: LOB/TXN Production Approval form is not required for ERA or EFT.


ERA and EFT available

Electronic Remittance Advice (ERA) is an electronic version of your Explanation of Payment or Electronic Remittance (EOP) and allows you to automatically post your accounts. If you currently receive ERA X12 835 files today, you will need to re-enroll through WPS Community Manager to receive ERAs from WPS.

Electronic Funds Transfer (EFT) is an electronic version of your paper check deposited directly into your checking or savings account. If you currently receive claim payments through EFT you will need to re-enroll through WPS Community Manager to receive EFT payments from WPS.

Please note: You will be notified when you can complete registration for ERA and EFT through WPS Community Manager.


PC-Ace Pro32 software users

If you are currently using PC Ace software to submit your claims, you will need to upgrade to the current version of PC ACE. If you do not use PC ACE and would like to, please download our new WPS version.


The new TRICARE East Region payer ID is TREST. It 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)

We also encourage you to contact your clearinghouse, billing service, or software vendor to discuss transition-related issues. A submitter (or trading partner) is someone who sends and receives electronic files. A submitter may be a provider and/or a clearinghouse.


How to contact the EDI team at WPS

We look forward to a successful relationship with our TRICARE East Region providers. If you have any questions or concerns regarding your claims transition, please contact us at:

EDI help desk team 1.800.782.2680 (option 1)
EDI marketing team 1.800.782.2680 (option 2)
Fax 1.608.223.3824
Email edi@wpsic.com