We are pleased to announce the US Defense Health Agency (DHA) has awarded Humana Military the next contract for the TRICARE East Region, partnering with you once again to serve our Active Duty Service Members (ADSM) and their families in the East Region.
While many processes and systems remain the same, we wanted to provide you with some updated information, as well as a helpful tips to ensure you have what you need in the coming year.
Read our FAQs for more information for providers staying in the East Region.
Claims Updates
New in 2025: Humana Military’s claims processor has switched from Wisconsin Physicians Service (WPS) to PGBA LLC, effective January 1, 2025. How does this impact you? Please find the process changes for claims and authorizations and claims-related processing:
Allowable charge reviews and claim payment disputes
Humana Military partners with our payer organization for processing those inquiries that are not medical necessity/non-covered benefit denials. Allowable charge reviews, claim reconsiderations and any claim payment-related inquires should be submitted to the address below.
Medical necessity and non-covered benefit claim appeals
Humana Military will continue to administer the medical necessity/non-covered benefit claim denials. New in 2025: We will offer an online appeals submission for those claims denied for medical necessity or non-covered benefits.
Allowable charge reviews and claim payment disputes
Humana Military partners with our payer organization for processing those inquiries that are not medical necessity/non-covered benefit denials. Allowable charge reviews, claim reconsiderations and any claim payment-related inquires should be submitted to the address below.
Referrals and Authorizations
To enhance efficiency and reduce processing times, the referrals and authorizations process has been streamlined in the new contract. Outpatient requests will no longer be accepted by fax; they must be submitted through provider self-service to allow for quicker and more accurate processing.
National Provider identifiers (NPI) and NPI matching logic
All covered entities are required to use their NPIs on HIPAA-standard electronic transactions in accordance with HIPAA Transaction Electronic Data Interchange for Health Care Providers Implementation Guide. The NPI billed on the claim will determine where payment, recoupment and remittances will be sent. All payments, recoupments and remittances will process to the Pay-to address or EFT bank account associated with the Primary NPI location.
All payments, recoupments and remittances for subordinate locations with the same NPI will roll up to the Primary NPI Pay-to or EFT bank account. If a separate payment address is needed, that separate payment address will require a separate NPI. When applicable rendering NPIs are also required. **Note all claims for ABA services must be filed electronically and must include the rendering NPI.
We thank you for your continued partnership to service the health care needs of our military families. Stay tuned for any additional updates, and if you have any questions about the items above, please call Humana Military at (800) 444-5445 or visit HumanaMilitary.com.
The newest TRICARE contracts begin on January 1, 2025. There will still be two regions in the United States. However, six current East Region states will move to the West Region: Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin. Humana Military will remain the contractor for the TRICARE East Region and TriWest Healthcare Alliance Corporation is the contractor for the West Region.
From now through December 31, 2024, your current TRICARE provider status remains “as-is” with Humana Military; therefore, continue to follow Humana Military’s procedures for Dates of Service (DOS) through December 31, 2024.
Below you will find a few instructions and reminders to support your transition to the West Region. Please look for communications from TriWest as well with additional instructions and next steps.
Read our FAQs for more information for providers moving to the West Region.
Claims
Humana Military and TriWest are working together to ensure the claims transition is transparent and seamless.
Referrals and authorizations
Effective January 1, 2025, all new referral/authorization requests or updates to existing referral/authorizations for beneficiaries in the West Region must be done through TriWest. Providers will have the ability to view existing referrals and authorizations through provider self-service for up to 180 days after January 1, 2025, but will not be able to make changes to them.
Resources
We thank you for your continued partnership to service the healthcare needs of our military families. You will also be hearing from TriWest in the coming weeks with additional information. In the meantime, please direct any questions during this transition to TriWest Healthcare Alliance at providerservices.triwest.com.