TRICARE provider with beneficiary

Claims

Effective June 1, 2018, any TRICARE East claims submitted to PGBA will be rejected and not forwarded to WPS. Therefore, all TRICARE East claims, regardless of the dates of service, should be submitted to WPS at:

TRICARE East Region
Wisconsin Physicians Service
Attention: Claims
PO Box 7981
Madison, WI 53707

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If you use a claims clearinghouse, please ensure they are aware of this change. If you do not use a claims clearinghouse, please submit your TRICARE claims online through self-service

Please note that TRICARE network providers are contractually required to submit all TRICARE claims electronically.

Humana Military would like to clarify some network contract terms associated with TRICARE claim reimbursement, use of the CHAMPUS Maximum Allowed Charge (CMAC) discount and the standard process to bill amounts. Learn more

Provider self-service has simplified the search for remittances. You can now search by check number to view all claims associated with that check. Learn more

Please note that all refunds should be sent to:
TRICARE East Region
Wisconsin Physicians Service
PO Box 8967
Madison, WI 53708-8967

As of 01/01/2018, all CHCPB claims should be sent to the following address:

TRICARE East Region
Claims Department
PO Box 7981
Madison, WI 53707-7981

Humana Military is in the process of printing and distributing new ID cards for our CHCBP beneficiaries. These new cards will display the correct claims mailing address.

Billing and filing guidelines

Wisconsin Physicians Service (WPS) is the claims processor for TRICARE East Region. WPS may delay or deny claims for a number of reasons. Explore these resources to find tips and educational information to help facilitate prompt claims processing.

Check status of claims

Providers can check the status of their TRICARE claims by logging in to self-service.

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REMINDER

To ensure accurate payment submissions to your provider location, please submit provider address updates in a timely manner to WPS at:

TRICARE East Region
Wisconsin Physicians Service
Attention: Correspondence
PO Box 8923
Madison, WI 53707

TRICARE rates

CHAMPUS Maximum Allowable Charges (CMAC) is the most frequently used TRICARE
reimbursement method for procedures or services. CMAC rates are determined by procedure code,
zip code, the setting where the services were rendered and the provider type.

View CMAC rates

Electronic claims submission

Learn how to quickly and easily submit claims
online with this step-by-step guide.

Access guide

TRICARE claims programs guidelines

TRICARE Prime & Select: Network providers must file claims for TRICARE beneficiaries. Non-network providers may accept assignment on a case-by-case basis. Payment made to network and non-network providers for medical services rendered will not exceed 100% of the TRICARE allowable charge. For non-network providers who do not accept assignment on the claim, beneficiaries will file, however, TRICARE will only allow up to 115% of the TRICARE allowed amount. Hold-harmless and balance-billing rules apply whether network or non-network.

Guidelines for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

CHAMPVA is not a TRICARE program. For questions or general correspondence, visit VHA Office of Community Care or call 1.800.733.8387. Claims for current treatment must be filed within 365 days of the date of service. Providers may file healthcare claims electronically on behalf of their patients. To file a paper healthcare claim, download CHAMPVA claim forms and file them within the one year claim filing deadline.

Send claims to:

VA Health Administration Center CHAMPVA
P.O. Box 469064
Denver, CO 80246-9064

Providers may request a written appeal if exceptional circumstances prevented them from filing a claim in a timely fashion. Send written appeals to:

VA Health Administration Center CHAMPVA
ATTN: Appeals
P.O. Box 460948
Denver, CO 80246-0948

Guidelines for the Continued Health Care Benefit Program (CHCBP)

Humana Military is the contractor for CHCBP and has partnered with WPS to process all CHCBP claims. CHCBP beneficiaries may request that providers file medical claims on their behalf. For questions and assistance regarding CHCBP claims, call WPS at 1.800.403.3950. While WPS is the East Region claims processor for TRICARE programs, CHCBP claims are filed to a different address within WPS. Filing claims correctly ensures timely and accurate claims payment. Note: Send claims for CHCBP beneficiaries with Medicare to WPS.

Providers can file CHCBP claims electronically by logging into Humana Military's self-service or by mailing paper claims to:

TRICARE East Region
Claims Department
PO Box 7981
Madison, WI 53707-7981

Guidelines for the Extended Care Health Option (ECHO)

  • All claims for ECHO and the DoD Enhanced Access to Comprehensive Autism Care Demonstration (CACD) must have a valid written authorization, and the beneficiary must show as enrolled in ECHO in DEERS.
  • All claims for ECHO-authorized care (including ECHO Home Health Care and the DoD CACD) must be billed on individual line items. Unauthorized ECHO claims will be denied.
  • ECHO claims will be reimbursed for the amount negotiated, the calendar year benefit limit or the TRICARE allowable charge, whichever is lower.
  • Each line item on an ECHO claim must correspond to a line item on the service authorization, or the claim may be denied or delayed due to research and reconciliation.
  • The billed amount for procedures must reflect the service, not the applicable ECHO benefit limits. Pricing of ECHO services and items is determined in accordance with the TRICARE Reimbursement Manual.
  • Refer to the TRICARE Policy Manual, Chapter 9, Sections 4.1, 11.1,14.1 and 18.1.

Guidelines for North Atlantic Treaty Organization (NATO)

TRICARE covers NATO foreign nations’ armed forces members who are stationed in the United States or are in the United States at the invitation of the U.S. government. They receive the same benefits as American ADSMs, including no out-of-pocket expenses for care if the care is directed by the military hospitals and clinics. NATO beneficiary eligibility is maintained in DEERS and claims submission procedures are the same as for American ADFMs. NATO family members follow the same prior authorization requirements as TRICARE Select beneficiaries and are responsible for TRICARE Select cost-shares and deductibles.

To collect charges for services not covered by TRICARE, providers must have the NATO beneficiary agree, in advance and in writing, to accept financial responsibility for any noncovered service by signing the TRICARE Noncovered Services Waiver form

TRICARE does not cover inpatient services for NATO beneficiaries. To be reimbursed for inpatient services, the NATO beneficiary must make the appropriate arrangements with the NATO nation embassy or consulate in advance.

Claims for Supplemental Health Care Program (SHCP)

The same balance-billing limitations applicable to TRICARE also apply to SHCP. WPS processes and pays claims for SHCP.

Send all TRICARE paper claims to:

TRICARE East Region
Wisconsin Physician Services
P.O. Box 8923
Madison, WI 53707

Claims for the US Family Health Plan (USFHP)

Although it provides a TRICARE Prime-like benefit, USFHP is a separately funded program that is distinct from the TRICARE program administered by Humana Military. The designated provider is responsible for all medical care for a USFHP enrollee, including pharmacy services, primary care and specialty care. If providing care to a USFHP enrollee outside of the network or in an emergency situation, do not file USFHP claims with Humana Military.

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Processing claims for out-of-region care

When providing healthcare services to a TRICARE beneficiary who is enrolled in a different region, the beneficiary will pay the applicable cost-share. Providers must submit reports and claims information to the region based on the TRICARE beneficiary’s enrollment address, not the region in which he or she received care. For claims issues or questions regarding a TRICARE beneficiary who normally receives care in another TRICARE region, call the appropriate region-specific number below for assistance.

1.800.444.5445 | East Region
1.877.874.2273 | West Region

TFL guidelines

  • File TFL claims first with Medicare.
  • Medicare pays its portion and electronically forwards the claim to WPS/TDEFIC (unless the beneficiary has OHI).
  • WPS/TDEFIC sends its payment for TRICARE-covered services directly to the provider. Beneficiaries receive Medicare summary notices and TRICARE Explanations of Benefits (EOBs) indicating the amounts paid.
  • For services covered by both TRICARE and Medicare, Medicare pays first and TRICARE pays its share of the remaining expenses second (unless the beneficiary has OHI).
  • For services covered by TRICARE but not by Medicare, TRICARE processes the claim as the primary payer. The beneficiary is responsible for the applicable TFL deductible and cost-share.
  • For services covered by Medicare but not by TRICARE, Medicare is the primary payer and TRICARE pays nothing. The beneficiary is responsible for the applicable Medicare deductible and cost-share.
  • For services not covered by Medicare or TRICARE: the beneficiary is responsible for the entire bill.

For more information about TFL, call WPS/TDEFIC at 1.866.773.0404 or visit TRICARE4u.com

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Processing claims for TRICARE for Life

TRICARE for Life (TFL) is Medicare-wraparound coverage for TRICARE beneficiaries eligible for Medicare Part A and enrolled in Medicare Part B. Medicare is the primary payer to TFL for all Medicare and TRICARE-covered benefits. However, beneficiaries may need an authorization from Humana Military if Medicare benefits are exhausted, or for care covered by TRICARE but not Medicare.

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TRICARE reimbursement methodologies

The TRICARE Reimbursement Manual provides the methodology for pricing allowable services and items
and for payment to specific categories and types of authorized providers.

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CAPPED DME

Durable Medical Equipment (DME) claims submitted require the appropriate modifier in order to track and calculate the monthly rental rate.

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CLAIMS AUDITING

We are required by TRICARE to review and implement claim auditing software to ensure correct code processing on claims.

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ELECTRONIC CLAIMS FILING

Network providers should file TRICARE claims electronically within 90 days of the date care was provided.

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No government pay list

The no government pay list is made up of procedures and services
outside of the scope of TRICARE and are considered non-covered.

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Home infusion injectable

Home infusion drugs are reimbursed according to TRICARE policy using HCPCS codes and NDC for pricing. We have compiled educational information to facilitate timely and accurate claim filing for reduction of billing errors, rework of claims and prompt payment of home infusion therapy services for TRICARE. Learn more

Office injectable

Educational information has been made available to facilitate timely and accurate claim filing for the prompt payment of provider office injectables. This guidance is provided to support the reduction of billing errors, rework of claims and diminish the possibility of payment error and recoupment of office injectables for TRICARE. Learn more

Claims processing standards & HIPAA guidelines

TRICARE requires providers to file claims electronically with the appropriate HIPAA-compliant standard electronic claims format.

HIPAA transaction standards and code sets: Providers must use the following HIPAA standard formats for TRICARE claims: ASC X12N 837—Health Care Claim: Professional, Version 5010 and Errata and ASC X12N 837—Health Care Claim: Institutional, Version 5010 and Errata. For assistance with HIPAA standard formats for TRICARE, call WPS EDI Help Desk at 1.800.782.2680 (option 1).

Other Health Insurance (OHI): If the patient has primary OHI, TRICARE providers must still file their patients’ TRICARE claims. If the OHI benefits are exhausted, TRICARE becomes the primary payer. In some instances an additional referral/prior authorization 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. View guidelines for identifying OHI in the claim form

To identify OHI in the claim form:

  • Mark Yes in Box 11d (CMS-1500) or FL 34 (UB-04)
  • Indicate the primary payer in Box 9 (CMS-1500) or FL 50 (UB-04)
  • Indicate the amount paid by the other carrier in Box 29 (CMS 1500) or FL 54 (UB-04)
  • Indicate insured’s name in Box 4 (CMS-1500) or FL 58 (UB-04)
  • Indicate the allowed amount of the OHI in FL 39 (UB-04) using value code 44 and entering the dollar amount

Resources

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Foreign claims

TOP claims information

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Submit claims online

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