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): 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.

Guidelines for identifying 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