TRICARE claims auditing

Per TRICARE policy, Humana Military is required to review and implement claim auditing software to ensure correct code processing on claims. As claims process, the coding is compared to the National Correct Coding Initiative Edits available through a third party vendor and will indicate the error rejecting the line of the claim with a reason code or message.

The TRICARE East Region uses a claims auditing tool to review claims on a prepayment basis. This auditing tool is an automated clinical tool that contains specific auditing logic designed to evaluate provider billing for CPT coding appropriateness and to monitor overpayment on professional and outpatient hospital service claims. Humana Military updates the claims auditing tool periodically with new coding based on current industry standards. Follow CPT coding guidelines to prevent claims auditing editing from resulting in claim denials. Claims auditing edits will be explained by a message code on the remittance advice.

The auditing tool also includes, but is not limited to, the following edit categories*:

  • Age conflicts
  • Alternate code replacements
  • Assistant surgeon requirements
  • Cosmetic procedures
  • Duplicate and bilateral procedures
  • Duplicate services
  • Gender conflicts
  • Incidental procedures
  • Modifier auditing
  • Mutually exclusive procedures
  • Preoperative and postoperative auditing billed
  • Procedure unbundling
  • Unlisted procedures

*The complete set of code edits is proprietary and, as such, cannot be released to the general public.

Providers disputing the reject or denial of services based on auditing can correct and resubmit under "corrected claim" with supporting documentation on a claim-by-claim basis. Please use these guidelines for reconsideration with a corrected claim. View reconsideration coversheet/tipsheet