TRICARE East Region Corrected Claims
PO Box 8904
Madison, WI 53708-8904
Fax: (608) 327-8523
PO Box 7981
Madison, WI 53707-7981
Fax: (608) 327-8522
We have implemented an EDI front-end editing change for NPI numbers on 837 professional claims, effective Jan. 12, 2019. Learn more
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.
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
The presence or absence of a state prevailing rate does not indicate policy coverage, payment approval or payment denial. Please note that the CHAMPUS Maximum Allowable Charges (CMAC) take precedence over state prevailing rates. View state prevailing rates
Learn how to quickly and easily submit claims
online with this step-by-step guide.
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.
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
P.O. Box 460948
Denver, CO 80246-0948
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 1.800.444.5445. 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
PO Box 7981
Madison, WI 53707-7981
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.
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.Learn more
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.
(800) 444-5445 | East Region
(877) 874-2273 | West Region
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.
For more information about TFL, call WPS/TDEFIC at 1.866.773.0404 or visit TRICARE4u.com
The TRICARE Reimbursement Manual provides the methodology for pricing allowable services and items
and for payment to specific categories and types of authorized providers.
TRICARE authorizes regional contractors to reimburse hospitals for allowed capital and direct medical education costs. Reimbursement is subject to regulations as outlined by TRICARE.
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
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
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 (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