TRICARE Claims Instructions

The Claims Instructions page is a resource to assist providers in effectively submitting claims and making claims inquiries.

Claims Submission

Submitting Electronic Claims

Electronic claim submission is required for TRICARE network providers and encouraged for non-network providers. Claims submitted electronically are less likely to be rejected compared to paper claims. Improve your claim submission accuracy and get your payments faster by signing up for electronic claim submission. Providers can enroll in an Electronic Data Interchange status (EDI).

NOTE: Network providers in Alaska are not required to submit claims electronically.

XPressClaim

XPressClaim is a secure, full-service online claims submission tool. This service is free to TRICARE providers and should be used when submitting attachments such as Other Health Insurance (OHI) details or Certificate of Medical Necessity (CMN). XPressClaim works best for providers who need to submit 150 claims or less per month. It is a one-claim-at-a-time product and does not batch submissions.

Learn More About Using XPressClaim

Claims Clearinghouses

If your clearinghouse already files claims to PGBA for other business lines, they will receive a notification along with an EDI FAQ to assist with the process of submitting TRICARE claims.

New direct submitters can establish clearinghouse services to transmit TRICARE claims electronically to PGBA for processing. The TRICARE West Region Payer ID is 99726.

Using Availity’s Basic Clearinghouse

Availity offers a Basic Clearinghouse option that allows TRICARE providers to submit electronic claims without needing a separate clearinghouse account. This service is free and easy to access.

Learn More About Claims Clearinghouses

Submitting Paper Claims

If electronic submission is not feasible, including network providers in Alaska, you can submit paper claims to TriWest. Paper claims must scan into an electronic format legibly and appropriately. Be sure to include all required information to prevent delays in processing.

Learn More About Submitting Paper Claims

Timeliness Requirements

Providers must submit TRICARE claims to PGBA for processing following the TriWest TRICARE Provider Handbook. Claims should be filed within one year after services are provided or within one year of discharge for inpatient admissions. To ensure timely payment, it's recommended to submit claims within 30 days of service. Additionally, claims must be submitted to PGBA within 90 days of Other Health Insurance (OHI) adjudication. Following best practices for claims submission is advised.

Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA)

Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) allow healthcare providers to securely receive payments and remittance information from TriWest.

To enroll electronically in EFT /ERA with TriWest, please follow the EFT/ERA enrollment instructions.

Once enrolled, TriWest will deposit payments directly into the designated bank account.

If you are unable to enroll electronically, please complete and submit the paper form in the PGBA EFT/ERA Enrollment Package and send to the fax number or address on the form.

Learn More About Timeliness Requirements and EFT/ERA

Claim Status

There are multiple ways for you to track the status of your patient claims.

Use Provider Portal to Check Status

You can check the status of claims through Availity. The Claim Status tool allows you to check the status of a submitted claim and view remittances. You can search claims by:

  • Member ID.
  • Tax ID & Service date.
  • Claim number.

If a claim is visible, it has been received. Please do not resubmit claims showing as in-process claims.

Call to Check Status

You can also check the status of your claims by calling TriWest without having to wait for a representative. After checking the status, you will be given the opportunity to speak with a representative.

The following information will be needed:

  • Providers NPI or TIN
  • Date of Service
  • Beneficiary’s DoD ID Number

The automated system will tell you if a claim is:

  • In Process: The claim is still pending and has not been paid or denied.
  • Denied: The claim has been denied, and the provider is referred to the Provider Remittance Advice (PRA) for further details.
  • Paid: The claim has been paid. It will also share the paid dollar amount and date.

Reconsiderations and Appeals

Providers can submit a claim review request for reconsideration when they need to dispute the outcome of a processed claim. OHI issues and timely filing denials are examples of issues that may need secondary review.

You can download the Provider Claims Reconsideration form. Please include all supporting documentation relevant to the review request. A claim reconsideration must be submitted no later than 90 days from the date of the remittance.

There are a few issues that providers are allowed to submit appeals. All appeal requests must be in writing and signed by the appealing party or the appealing party’s representative.

Learn More About Reconsiderations and Appeals

Overpayments and Refunds

To refund an overpayment, please submit the payment with supporting documentation to identify the overpaid claim to the address below.

TRICARE West Finance
P.O. Box 202162
Florence, SC 29502-2162

Timeliness Requirements

Providers must submit TRICARE claims to PGBA for processing following the TRICARE West Region Provider Handbook. Claims should be filed within one year after services are provided or within one year of discharge for inpatient admissions. To ensure timely payment, it's recommended to submit claims within 30 days of service. Additionally, claims must be submitted to PGBA within 90 days of OHI adjudication. Following best practices for claims submission is advised.

Timely Filing Waivers

According to TRICARE guidelines, providers must file claims within one year from the date of service or the discharge date for inpatient services. TRICARE denies claims received after the deadline. A timely filing waiver can be requested by providing documentation that proves certain conditions.

Learn More About Timely Filing Waivers

Fraud, Waste, and Abuse (FWA)

Health care fraud is knowing and willful deception or misrepresentation by a provider, beneficiary, sponsor, or any person acting on behalf of a provider, beneficiary, or sponsor, with the knowledge that the deception or misrepresentation could result in benefits and payments that the recipient is not entitled to. Fraud requires intent and knowledge that the action is improper.

TriWest utilizes pre-payment and post-payment fraud detection tools and resources to monitor and analyze various beneficiary, provider, and claim data for potential fraud, waste, and abuse. Providers are responsible for submitting accurate and appropriate billing for all services billed to TRICARE.

Abuse is any practice that is inconsistent with accepted sound fiscal, business, or professional practice. Abuse may not carry sufficient evidence of intent and knowledge to constitute fraud, and it may be difficult to conclusively establish whether the actions are due to willful deception or are based on subjective clinical judgement.

TriWest has established a Program Integrity team dedicated to stop fraud and abuse in the TRICARE program. TriWest takes all allegations of fraud and abuse seriously and completes a thorough investigation of the allegations. TriWest will report cases to the government for further investigation and possible legal action when evidence of fraud and abuse is substantiated.

Learn More About Fraud, Waste, and Abuse

Other Health Insurance (OHI)

Active-Duty Service Members

TRICARE is the primary payer for active-duty service members, including activated National Guard and Reserve members. These members should not use OHI as their primary coverage. TRICARE is primary and does not coordinate benefits with other insurers.

All Other Beneficiary Categories

TRICARE and OHI work together to coordinate benefits for payment. By law, TRICARE pays after their OHI. If a beneficiary has health coverage through an employer, private insurer, or school, their OHI is always their primary insurance and would pay before TRICARE. If TRICARE receives the claim before OHI processes it, TRICARE will deny it.

If you believe TRICARE has erroneous OHI record(s), please contact the beneficiary to update their OHI.

Learn More About Other Health Insurance

Reimbursement

To learn more about how payments are calculated with OHI, please review TRICARE Reimbursement (TRM) Chapter 4, Section 2 and 3.

TRICARE and Secondary Payment

If TRICARE is the secondary payer after OHI, providers must submit claims to the primary payer before billing TRICARE. Fill out the appropriate Coordination of Benefits (COB) loops and segments on electronic claims submissions. It is the provider’s responsibility to ask the beneficiary if they have OHI that is primary to TRICARE.

Authorizations and Referrals

To see if an authorization or referral is required for a specific procedure, go to the Provider Portal at www.availity.com and log in under the TRICARE payer space. Once here, a provider can easily submit a request for prior authorization.

See Referrals/Authorizations Guidelines Page

Balance Billing

Balance billing occurs when a provider bills a TRICARE beneficiary for any amount more than the TRICARE-allowable charge after TRICARE has processed the claim. TRICARE prohibits the practice of balance billing.

Moonlighting

Moonlighting is the practice of healthcare professionals providing services outside of their position under TRICARE. There are limited circumstances where moonlighting providers are permitted to treat TRICARE beneficiaries, such as providing emergency services.

Hold Harmless

If a beneficiary received any excluded or excludable services from a network provider, that provider must not require payment (i.e., the beneficiary will be held harmless) The are a few exceptions. General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or excludable.

Learn More About Balance Billing, Moonlighting and Hold Harmless