Claims processing standards and 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 (800) 782-2680 (option 1).

Other Health Insurance (OHI)

Since OHI status can change at any time, always ask all beneficiaries about OHI, including National Guard and Reserve members and their families. 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.

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.

In order 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.

See OHI information in the provider handbook