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I am staying in the East region I am moving to the West region

Providers staying in the East Region

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:  

  • EDI Claims: The 2025 TRICARE East Payer ID is 99727.
  • Claims-related document submissions:
    • XPressClaims will be the online claims and claims-related document submission system beginning January 1, 2025, and will be available in provider self-service. 
    • For the Clearinghouse, new direct submitters must file a trading partner agreement and enrollment form in order to be assigned a mailbox/submitter ID. If your clearinghouse already files claims to PGBA for other lines of business, you need to ensure that the TRICARE EAST payer ID 99727 is made available as an option.  If your clearinghouse does not submit to PGBA, providers, vendors or clearinghouses that can create an ANSI X12 electronic file, and have telecommunications capabilities, can upload files to PGBA directly. Batch claims processing is available through our EDI Gateway mailbox system. More resources to come for how to submit claims-related documents. Providers must file a PGBA EDI Provider Agreement in order to submit claims electronically.
  • Document and claims submission during payer transition:
    • Claims with 2024 Dates of Service (DOS):
      • From January 1, 2025, to April 30, 2025, the current payer organization (WPS) will continue to process claims with a 2024 DOS. After April 30, 2025, claims with a 2024 DOS will no longer be accepted via 2024 processes. To assist with processing a 2024 claim to completion prior to April 30, 2025:
        • Submit payer requested claim documentation timely.
        • Submit claim requests/disputes related to claim denials timely to allow for current payer processing. 
      • Beginning May 1, 2025, submit 2024 claims and claims-related documents to XPressClaims through provider self-service or the clearinghouse
  • Providers should sign up for ERA/EFT to ensure timely receipts of remittances and payments. Even if you have EFT/ERA currently, you will need to sign up again for EFT/ERA by January 1, 2025.  Please note: T17 EFT/ERA applications will not be accepted after January 1, 2025. 

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.

Providers moving to the West Region

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.

  • When a claim is received, it is processed by eligibility and DOS. 
    • If a beneficiary’s eligibility and DOS is under the East Region, the claim stays with the East to process.
    • If the DOS and eligibility is under the West Region, Humana Military will reroute the claim to TriWest.
  • Claims with 2024 DOS: Submit and research claims as normal via Humana Military provider self-service and the claims function in our automated phone system.  
    • You will not lose access to provider self-service. However, the link to WPS will only be available in self-service 120 days after January 1, 2025. At that time, the WPS link will be removed and all claims will transition to the new claims processor, PGBA LLC.  
    • View your claims history for dates of service prior to January 1, 2025, (and submitted prior to May 1, 2025) by accessing the, “See claims with dates of service prior to Jan. 1, 2025,” on provider self-service. If you do not see your claim listed, please visit TriWest’s provider portal at Availity Provider Portal QRG.
  • Claims with 2025 DOS: Visit TriWest’s provider portal
  • Paper Claims: To ensure claims are processed in a timely manner claims will need to be submitted to the correct mailing address based on eligibility and DOS.
    • For all Claims submissions between January 1, 2025 – April 30-2025, with a DOS of 2024, or older, submit to:
      TRICARE East Region claims
      PO Box 7981
      Madison, WI 53707-7981

    • For all Claims submissions on or after May 1, 2025, with a DOS of 2024, or older, submit to:
      TRICARE EAST Region
      PO Box 202146
      Florence, SC 29502-2146

    • For all West Region Claims submissions with a DOS of 2025 and after, submit to TriWest:
      TriWest
      PO Box 202160
      Florence, SC 29502-2160
  • Please note: T17 EFT/ERA applications will not be accepted after January 1, 2025. 

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

  • TriWest’s provider portal: Register for a free account on Availity.com, which TriWest uses as its secure provider poral. If you don’t already have an account on Availity, register now at Availity.com. If you need help with registration or have questions about your Availity account, call Availity at (800) 282-4548.
  • TriWest West Region Provider Handbook Contains information about program requirements, claims submissions, eligibility, referrals and authorizations and beneficiary out-of-pocket costs.

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.