Emergency room charges in conjunction with a DRG-reimbursed hospital stay must be billed on a separate outpatient UB-04. Additionally, ambulatory surgery room charges cannot be submitted on an inpatient claim and should be billed as a separate outpatient service on the UB-04 (revenue code 049X).
Interim claims for DRG-based facilities (regardless of the type of contract with Humana Military) are accepted when the patient has been in the hospital at least 60 days. If you submit multiple claims on one patient’s behalf, you must submit them in chronological order. Fixed-dollar parameters do not apply.
Hospital-based outpatient surgical procedures are reimbursed under the TRICARE Outpatient Prospective Payment System (OPPS). Some hospitals are exempt from OPPS. This is mandatory for both network and non-network providers. TRICARE’s OPPS closely mirrors Medicare’s OPPS method; however, the TRICARE program determines benefits and coverage for the entire military population, regardless of age. For a list of exempt facilities, procedure code change for TRICARE’s No Government Pay List and more information regarding TRICARE OPPS implementation, refer to the TRICARE Reimbursement Manual, Chapter 13. TRICARE-OPPS exempt facilities reimburse rates established by TRICARE for outpatient surgical procedures. To ensure proper payment for procedures listed on the TRICARE Ambulatory Surgery Center (ASC), make sure that ICD-10 surgical procedure codes have a corresponding CPT code and a charge for each CPT code billed.
Certain surgical procedures normally reimbursed at a hospital-based surgery center can also be reimbursed at a freestanding ASC. TRICARE network providers must contact Humana Military to obtain prior authorization for appropriate procedures performed at an ASC. Refer to the TRICARE Policy Manual, Chapter 11 for more information.
Hospital clinic billing: When billing for provider outpatient services in a hospital setting, the following guidelines must be followed. This allows the claim to process in a timely manner and keeps the TRICARE beneficiary from being charged a double copay.
Change in hospital classification: TRICARE-authorized hospital providers must immediately inform Humana Military of any change in CMS hospital classification. Notification by the hospital must occur if the provider changes classification from a short term acute care hospital, critical access hospital or sole community hospital to any other of the three noted classifications. This allows Humana Military to properly reimburse hospitals for TRICARE-covered services.
When notifying Humana Military, providers should include the official letter from CMS, the hospital’s point of contact information and the effective date of the CMS hospital classification change. Providers may mail this required information to Humana Military:
TRICARE East Region
P.O. Box 8923
Madison, WI 53707-8923