TRICARE Claims Instructions

The Claims Instructions page assists providers with submitting claims and making claims inquiries.

Claims Submission

Introduction

This guide will help you submit claims. Submitting claims electronically is mandatory for TRICARE network providers (except in Alaska) and is recommended for non-network providers.

Submit Electronic Claims with a Clearinghouse

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. You can improve your claim submission accuracy and get your payments faster by signing up for electronic claim submission.

Please see the options below for submitting claims electronically.

Claims Clearinghouses:

• If your clearinghouse already files claims to PGBA, PGBA should have contacted your clearinghouse on how to submit claims under TRICARE. Your clearinghouse needs to make sure the TRICARE West payer ID 99726 is made available as an option.
• New direct submitters can establish clearinghouse services to transmit TRICARE claims electronically to PGBA for processing. Ensure your clearinghouse or vendor uses Payer ID 99726 when submitting claims to PGBA. Start by reviewing and submitting the forms below from the TRIWEST – TRICARE payer space on Availity or Provider Forms section under Claims. Submission instructions are located within the guides.
  • Download the EDI Trading Partner Agreement.
  • Fill out the Enrollment form found in the appendix of the EDI Gateway User manual.
• PGBA will notify you once the forms above are processed and you are ready to submit claims under your Clearinghouse. Please be sure to review the EDI Vendor/Clearinghouse Disclaimer located at https://www.palmettogba.com/disclaimer.

For further assistance, contact the TRICARE EDI Help Desk for the West Region by phone at 1-800-259-0264 or via email at EDI.TRICARE@PGBA.com.

Submit Claims Without a Clearinghouse through Availity

You can submit claims through the Availity provider portal if you don’t use a clearinghouse by logging in or registering on Availity.com.

• Navigate to the Claims & Payments and select Claims & Encounters from the dropdown menu.
• Populate the required fields, ensuring you select TRIWEST – TRICARE as the Payer.
• Follow the prompts and submit your claim.

Submit Claims Without a Clearinghouse through 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 since it is not a batch system but a one-claim-at-a-time product.

You can submit claims via XPressClaim by logging in or registering on Availity.com.

• Navigate to the TRIWEST-TRICARE Payer Space.
• From the Applications tab, select XPressClaim Claim Submission.
• In the next screen, select your Organization and Provider you would like to submit claims for and hit Submit.
• You will be taken to the XPressClaim enrollment page. Enroll your user by following the prompts.
• After enrolling, work through the prompts to submit your claims. After you have enrolled in XPressClaim. Submit your claim through XPressClaim.
• For any subsequent XPressClaim sessions, you just need to follow the steps below without needing to re-enroll.
  • Navigate to the Applications tab.
  • Select XPressClaim Claim Submission.
• Select your organization from the Select an Organization drop-down menu.
• Select the correct provider in the Select a Provider drop-down menu.
• Select Submit. This will open the third party website. Once there, follow the on-screen instructions.

Note: XPressClaim only lets you submit one claim at a time. It is not a batch claims system. XPressClaim works best for providers who submit 150 claims or less per month. You can also review the Introduction to XPressClaim web training in the Availity Branded Learning Center.

Submit Paper Claims:

• Scan paper claim into an electronic format legibly and appropriately. When filing paper claims, you must use one of the following:
  • A CMS 1500 form (for professional charges).
  • A CMS UB-04 form (for institutional charges).
• Include all required information to prevent delays in processing:
  • Completed Claim Form: Fill out all sections of the claim form accurately.
  • Supporting Documentation: Attach any necessary documentation, such as itemized bills or medical records.
  • Provider Information: Include your provider information, such as name, address, and National Provider Identifier (NPI).
• Mail to TRICARE West Claims, P.O. Box 202160, Florence, SC 29502-2160.

Benefits of Using Availity Essentials

Register on Availity to:

• Enroll in EDI claims submission. Electronic submission is encouraged!
• Check claim status.
• View/print a TRICARE Remittance Advice.
• Enroll in Electronic Funds Transfer and/or Electronic Remittance Advice.

Reconsiderations and Appeals

Providers can submit a claim review request for reconsideration when they need to dispute the outcome of a processed claim.

Examples of issues that may need secondary review include:

• Allowed amount disputes.
• Other health insurance issues.
• Timely filing denials.
• Penalties for no authorization.
• Denial code(s).

Download the Provider Claims Reconsideration form and mail or fax to the address below. 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.

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450
Fax: 1-866-852-1969

There are a few issues that are appealable:

• Claims denied due to TRICARE policy limitations.
• Claims denied as not medically necessary.
• Claims processed as POS only when the reason for dispute is that the service was for emergency care.

Only the following individuals may file an appeal:

• The beneficiary (including minors).
• The parent or guardian representing a minor or beneficiary.
• The non-network participating provider of services.
• A representative appointed by the proper appealing party (Must be in writing and be signed by the proper appealing party, or the representative must be court-appointed).

All appeal requests must be in writing and signed by the appealing party or the appealing party’s representative. The appeal request must state the issue in dispute. A copy of the initial denial (EOB/ provider remittance advice) and any additional documentation in support of the appeal should be submitted with the request. An appeal request must be received within 90 days of the date on the remittance advice.

Providers should mail or fax appeal requests to:

TRICARE West Claims Appeals
P.O. Box 2777
Virginia Beach, VA 23450
Fax: 1-866-670-4330

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

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 one of the following:

• Retroactive eligibility or authorization was issued after the filing deadline.
• The patient was mentally incompetent and did not have a legal guardian appointed.
• The claim was submitted before the filing deadline. (Note: Only claims that have been assigned a claim number can be appealed.)
• The Explanation of Benefits (EOB) from the patient’s other health insurance (OHI) was received within the TRICARE filing deadline, and the claim was submitted to TRICARE within 90 days from the date of the OHI decision.

Providers can send requests for a timely filing waiver to:

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450