Claims Processing and Billing Information
On behalf of the DOD, TriWest is the third party administrator (TPA) and payer for the TRICARE West Region.
TriWest partners with claims processor PGBA to process and pay claims to TRICARE providers who have rendered services to beneficiaries in accordance with TRICARE policies and procedures.
Claims Processing Standards and Guidelines
All claims for TRICARE-covered services must be submitted to PGBA for claims processing in accordance with the TriWest TRICARE Provider Handbook, no later than one year (365 days) after services are provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility or an ancillary provider participating in the inpatient care. To ensure timely submission and payment, TriWest strongly recommends filing claims within 30 days of the date of service. The claim must be submitted to PGBA within 90 calendar days from the OHI adjudication date.
TRICARE requires electronic claims be filed using the appropriate HIPAA-compliant and standard electronic claims format. If a non-network provider must submit paper claims, TRICARE requires use of either a CMS 1500 (professional charges) or a CMS UB-04 (institutional charges) claim form.
Completion of claim forms and claim form requirement information can be found online.
Electronic Claims Submission
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. You can do this by enrolling in Electronic Data Interchange (EDI) through PGBA.
The following options are available for electronic claims submission:
- XPressClaim – A secure, full-service online claims submission tool. Claims clearinghouses – A third-party organization that acts as a middleman between healthcare providers and insurance companies, or other payers, to process medical claims electronically.
- Availity’s Basic Clearinghouse – The TriWest self-service secure provider portal.
Network Providers – Submit Electronically: Use Payer ID 99726.
For more information on how to submit claims electronically using the options above, please go to https://tricare.triwest.com.
Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
TriWest providers can enroll online for EFT and/or ERA through the Availity Essentials Transaction Enrollment application. Your organization’s Availity administrator can set up user account access and assign roles and permissions to ensure you receive payments more quickly and avoid the hassle of paper checks and/or remits.
Enroll by following these steps:
- Log into Availity and navigate to Availity Essentials.
- Select My Providers > Enrollment Center > Transaction Enrollment
- With Transaction Enrollment permission the user can enroll a single provider or providers in bulk (up to 500 at a time).
Claims Submission Addresses
Paper claims can be mailed or faxed to the address below:
TRICARE West Claims
P.O. Box 202160
Florence, SC 29502-2160
Fax Number 1-877-989-0070
TRICARE Billing Policies and Tips
Beneficiary Signature on File – Using the signature on file procedure is the provider’s indication that he or she agrees that verification of the beneficiary’s TRICARE eligibility at the time of admission or at the time care or services are provided is required before any TRICARE payment.
Please refer to the TRICARE Operations Manual, Chapter 8, Section 4 to learn more about signature requirements.
Referrals – Network providers should hold beneficiaries harmless “held harmless” (i.e., considered not financially responsible for any charges) in cases where the provider fails to request a referral and the contractor either denies payment or applies Prime Pont of Service (POS) option.
Claim Processing Timelines – 98% of retained and adjustment claims will be processed to completion within 30 calendar days from the date of receipt.
Other Health Insurance (OHI) – It is the provider’s responsibility to ask the beneficiary if they have OHI that is primary to TRICARE and submit the claim to primary payer before claim is filed with TRICARE. If TRICARE receives claim before OHI processes it, the claim will be denied.
National Provider Identifier (NPI): Providers in a Group should submit claims with their individual and group NPI:
- Enter Type 1 NPI in CMS 1500 form Field 24J
- Enter Type 2 NPI in Field 33A as billing provider
- Solo Practitioners: Use individual NPI in Field 33A only
Corrected/Void Claims – A corrected claim should be submitted when you need to replace or correct information on a claim that was previously submitted and/or processed by PGBA. Submitting a corrected claim will have the effect of completely replacing your previously filed claim with the information on the corrected claim.
Examples of a corrected claim include (but are not limited to):
- Providing a referral number or rendering NPI originally omitted
- Changing procedure or diagnosis codes, or the patient’s name or demographic information, or any other information that would change the way the claim was originally processed
Submit a void claim when you need to cancel a claim already submitted and/or processed by PGBA.
How to File a Corrected/Void Claim
Electronic submissions:
To submit a corrected claim or claim void electronically using forms 837I or 837P:
- Find Loop 2300 (Claim Information)
- In segment CLM05-3, enter correct frequency code value:
- 7 – Replacement of prior claim
- 8 – Void/cancel prior claim
- In segment REF01, enter F8
- In segment REF02, enter original claim number
Complete all other claim fields as normal.
Paper submissions:
To submit a corrected claim or claim void by paper, follow the instructions below.
CMS 1500:
- Use the following frequency code in Box 22 and make sure it is left justified
- Frequency code 7: Replacement of Prior Claim: Corrects a previously submitted claim.
- Frequency code 8: Void/Cancel of Prior Claim: Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims.
- In the Original Reference Number space, enter the original claim ID.
UB04:
- Find Box 4 - Type of Bill (top, right-hand corner). Enter the correct resubmission code below in the third digit of the bill type
- Frequency code 7: Replacement of Prior Claim: Corrects a previously submitted claim.
- Frequency code 8: Void/Cancel of Prior Claim: Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims.
- Find Box 64 – Document Control Number and enter the original claim ID.
Billing duplicate services on same day: The same procedure code cannot be billed on multiple lines for the same date of service when no modifier is billed to distinguish the services because it is considered a duplicate procedure. Instead, please bill procedure code on one line with multiple units. If the same procedure was performed on different DOS, please bill each line separately instead of billing a date range on one line.
Emergency room charges with inpatient facility stay: Emergency room charges in conjunction with a DRG-reimbursed hospital stay must be billed on a separate outpatient CMS UB-04 form. In addition, ambulatory surgery room charges cannot be submitted on an inpatient facility claim and should be billed as a separate outpatient service on the CMS UB-04 form.
Interim claims: Interim bills are accepted when the beneficiary has been in the hospital at least 60 days. Please submit interim bills in chronological order.
Please refer to the TRICARE Policy Manual (TPM) to learn more about billing and policies surrounding specific types of care. The TPM is searchable by keyword.
Maximum Number of Services Limitation
TRICARE’s maximum number of services per day that may be billed for specific procedure codes can be found on the Rates and Reimbursement webpage, under Limits on Number of Services without Override Code. If the number of procedures performed in a day exceeds the limit, medical documentation will be required to support medical necessity.
Claims Status Check
Providers can check the status of claims through Availity. The tool gives providers a more intuitive and robust workflow to check the claim status of a beneficiary. The Claim Status tool allows providers to check the status of a submitted claim and view remittances.
Providers can also search claims by:
- Member ID
- Tax ID Service date
- Claim number
If a claim cannot be found, there may have been errors with the submission. If a claim is visible, it is in process. Please do not resubmit claims showing as in-process claims.
For missing claims, please verify that:
- It has been at least 10 business days since the claim was submitted electronically or 15 business days since the provider mailed the claim
- A paper claim was not handwritten and all information was typed correctly
Telemedicine Billing
Conditions of payment include:
- Synchronous telemedicine services
- Asynchronous telemedicine services
Synchronous. For a TRICARE payment to be authorized for synchronous telemedicine services between a provider and patient, interactive telecommunication systems, permitting real-time audio and video communication between the TRICARE-authorized provider (i.e., distant site) and the beneficiary (i.e., originating site) must be used.
As a payment condition for synchronous telemedicine services, both the patient and health care provider must be present on the connection and participating in the telemedicine service.
Asynchronous. TRICARE allows payment for asynchronous telemedicine services in which, under conventional health care delivery, do not require face-to-face or “hands-on” contact between patient and provider. For TRICARE payment to be authorized for asynchronous telemedicine services, interpretive services must be rendered by the consulting provider to the referring provider.
Please refer to TRICARE Policy Manual (TPM) Chapter 7, Section 22.1 to learn more about telemedicine coverage and billing.
Eye Exam Coverage
TRICARE Select ADFMs are entitled to one annual routine eye examination. Prime ADFMs may receive their annual routine eye examination from any network provider without a referral, authorization, or pre-authorization from the PCM or any other authority (i.e., a Prime ADFM will be allowed to set up his or her own appointment for a routine eye examination with any network optometrist or ophthalmologist). TRICARE Select ADFMs may self-refer to any TRICARE authorized provider regardless of whether or not they are a network provider (i.e., they may set up their own appointment with either a network or non-network, TRICARE-authorized, optometrist or ophthalmologist).
Routine eye exams are covered once every two years for retirees and eligible family members who are enrolled in TRICARE Prime. Routine eye exams are not a covered benefit for retirees and eligible family members who are enrolled in TRICARE Select. ADFMs who are enrolled in TRICARE Prime or TRICARE Select may receive a routine eye exam annually.
Please refer to TRICARE Policy Manual (TPM), Chapter 7, Section 6.1 to learn more about Ophthalmological services.
Billing for Mutually Exclusive Procedures
TriWest does apply editing to detect mutually exclusive procedures that cannot reasonably be performed at the same anatomic site or same beneficiary encounter.
Non-Covered Services
It is the provider’s responsibility to ensure services are covered before delivering care. Non-covered services include:
- Services that appear on the No Government Pay Procedure Code List
- Services outside of the scope of TRICARE-covered services
- Services that currently have a temporary code or are considered experimental or investigational by the FDA.
If services are considered non-covered, providers must notify TRICARE beneficiaries in writing before delivering care.
In certain circumstances, ADSMs may be approved for non-covered services if authorized or a waiver is received from MTF.
Physician-Administered Drug and Vaccine Claim Filing
The National Drug Code (NDC) number, drug quantity, and unit of measure are required on drug and vaccine claims when there is no nationally established TRICARE-allowable charge. Please visit the TRICARE Allowable Charges website to determine if a TRICARE-allowable charge exists for specific drugs or vaccines.
Please see below for details on how to properly bill NDC number, drug quantity, and package unit fields.
Professional Paper Claim Guidelines (CMS-1500) – In the shaded portion of the line-item field 24A-24G on the CMS-1500, enter the qualifier N4 (left-justified), immediately followed by the NDC. Next, enter one space for separation, then enter the appropriate qualifier for the correct dispensing unit of measure (UN, ML, GR, or F2), followed by the quantity (number of NDC units up to three decimal places).
Institutional Paper Claim Guidelines (CMS UB-04) – In the line-item field 42-46, enter the appropriate drug-related revenue code in field 42. In field 43, report the NDC qualifier N4 (left-justified), immediately followed by the 11-character NDC in the 5-4-2 format (no hyphens). Immediately after the last digit of the NDC, enter the appropriate qualifier for the correct package size, NDC unit of measure (UN, ML, GR, or F2), followed by the quantity (number of NDC units up to three decimal places).
Please be sure to include the N4 before the 11-digit NDC number, but do not include drug name on the claim form. If the drug name is included on the claim form, this may result in the claim being denied.
Use the following data elements to submit the NDC information in the HIPAA-standard ASC X12N 837 electronic claims format.
- Loop 2400, segment SV101 = CPT/HCPCS code
- Loop 2400, segment SV104 = CPT/HCPCS units
- Loop 2410, segment LIN02 = N4 qualifier
- Loop 2410, segment LIN03 = 11-digit NDC number
- Loop 2410, segment CPT04 = NDC quantity
- Loop 2410, segment CPT05 = NDC unit or basis for measurement code (UN, ML, ME, F2, GR)
Processing Claims for Out of Jurisdiction
For beneficiaries not enrolled in TRICARE Prime, the provider will submit claims to the contractor responsible for the jurisdiction using the beneficiary’s home address on the claim regardless of where the service was received. (See the TRICARE Systems Manual (TSM), Chapter 3, Section 4.2, if the beneficiary’s home address on the claim differs from the home address on DEERS).
Extended Care Health Option (ECHO)
ECHO services reimbursement will be applied in accordance with the TRM. Refer to the TPM, Chapter 9 and the TOM to learn more about ECHO claims.
Autism Care Demonstration
ACD services reimbursement will be limited to the specific ACD CPT codes, rates are listed in the ACD Toolkit.
The Government will update ACD reimbursement rates at the same time as the annual CHAMPUS Maximum Allowable Charge (CMAC) update. ACD reimbursement rates are effective each May 1st.
Negotiated rates lower than those listed are not permitted.
TRICARE-Authorized Non-Network/Non-Participating Providers
Once an agreement is signed to become a TRICARE network provider, you agree to be paid the lesser of the TRICARE maximum allowable charge or your contracted rate. If you are a non-network TRICARE-authorized provider and have agreed to participate on a claim, this means you have agreed to accept the TRICARE-allowable charge as payment in full for this claim and you may not bill patients for any amount in excess of the TRICARE-allowable charge. Non-network providers who do not accept assignment are limited by federal balance billing laws on how much they can bill TRICARE beneficiaries.
By federal law, non-participating providers may not balance bill the beneficiary more than 15% above the allowable charge. When the billed amount is less than 115% of the allowed amount, the provider is limited to billing the billed charge to the beneficiary. The balance billing limit shall be applied to each line item on a claim.
See the TRICARE-allowable charge schedules for more information.
TRICARE Balance Billing and Collection Activities
Balance billing occurs when a provider bills a TRICARE beneficiary for any amount exceeding the TRICARE-allowable charge after TRICARE has processed the claim. This practice is limited by law. TRICARE prohibits the practice of balance billing. Balance billing requirements apply to both network and non-network providers who treat TRICARE beneficiaries. Noncompliance can impact your TRICARE and/or Medicare status.
Both network and non-network providers are encouraged to explore all available options to resolve claims issues. The involvement of a debt collection agency is strongly discouraged.
Beneficiaries are responsible for their out-of-pocket expenses reflected on the TRICARE Summary Payment Voucher/Remit, including deductible, cost-share and/or copayment amounts.
TRICARE and Other Health Insurance (OHI)
TRICARE is always the primary payer for ADSMs (including National Guard and Reserve members). For other beneficiary categories, TRICARE pays secondary to Medicare and other primary coverage.
If TRICARE is the secondary payer, the provider is required to submit claims to the primary payer before billing TRICARE. Provider must include the OHI EOB with paper claim submission, or fill out appropriate COB loops and segments on the electronic claim submission.
TRICARE requires an acceptable reason from OHI for non-payment before a claim can be considered payable. To coordinate benefits, the EOB/COB must reflect the beneficiary’s liability (copayment, deductible and/or cost-share), original billed amount, allowed amount, and/or any discounts. The claim will be denied if there is indication of primary OHI and the claim is submitted without other payer EOB or COB payment information.
Other Health Insurance (OHI) Claims
The below services require a TRICARE pre-authorization regardless of OHI:
- Adjunctive dental care
- Advanced life support air ambulance in conjunction with stem cell transplantation
- All inpatient behavioral health and substance abuse disorder (SUD) services (inpatient services, SUD, substance use disorder rehabilitation facility, and RTC residential treatment center)
- All solid organ and stem cell transplants
- ABA services
- ECHO
- Electroconvulsive therapy
- Home health services, including home infusion
- Hospice
- Intensive outpatient programs
- Laboratory developed tests
- Low protein modified foods
- Medication-assisted treatment
- Non-emergency admissions, to include detoxification and rehabilitation services
- Open, arthroscopic, and combined hip surgery for the treatment of Femoroacetabular Impingement
- Opioid treatment programs (OTPs)
- Partial hospitalization program (PHPs)
- Psychoanalysis
- Psychological testing
- Residential Treatment Centers (RTC)
- Transcranial Magnetic Stimulation
- Transplants (solid organ and stem cell, not corneal transplant)
Identify OHI in the claim form:
- Mark “Yes” in Box 11d (CMS 1500 claim form) or FL (CMS UB-04 claim form)
- Indicate the primary payer in Box 9 (CMS 1500 claim form) or FL 50 (CMS UB-04 claim form)
- Indicate the amount paid by the OHI in Box 29 (CMS 1500 claim form) or FL 54 (CMS UB-04 claim form)
- Indicate insured’s name in Box 4 (CMS 1500 claim form) or FL 58 (CMS UB-04 claim form)
- Indicate the allowed amount of the OHI in FL 39 (CMS UB04 claim form) using value code 44 and entering the dollar amount
Please refer to TRICARE Reimbursement Manual, Chapter 4, Section 3 to learn more about how TRICARE coordinates benefits.
Durable Equipment (DE): Basic Program Billing Guidelines
Please refer to TRICARE Policy Manual, Chapter 8, Section 2.1 to learn more about Durable Equipment (DE). This section includes coverage criteria and exclusions, as well as other relevant criteria.
Ambulatory Surgery Center Charges
All hospitals or freestanding ASCs must submit claims for ambulatory surgery procedures on a CMS UB-04 claim form.
Please refer to TRICARE Policy Manual, Chapter 11, Sections 6.1 and 6.2 to learn more about Ambulatory Surgery and Freestanding Ambulatory Surgery Centers
TRICARE and Third-Party Liability Insurance
TriWest will identify claims with possible third party involvement and recover costs for medical care furnished, or paid for, on behalf of a TRICARE beneficiary.
Please refer to TRICARE Operations Manual, Chapter 10, Section 4 to learn more about Third Party Recovery Claims.
TRICARE and Workers’ Compensation
TRICARE will not reimburse services covered under workers’ compensation programs.
TRICARE Claim Reconsiderations
Providers can submit a request for claim review when they need to dispute the outcome of a claim that was previously submitted and processed. It is appropriate to submit a request for claim review when a provider believes the information originally submitted was complete and accurate (to their knowledge), but they disagree with the claim determination and are requesting a secondary review.
If a provider is submitting additional or different information that was NOT included in the original claim submission which resulted in a denial or payment discrepancy, please DO NOT submit a request for claim review. Any changes to a previously submitted and or processed claim should be filed through the corrected claims process.
Examples of issues that are considered reviewable would include, but are not limited to:
- Allowed amount disputes
- OHI issues
- Timely Filing denials
- Penalties for no authorization
- Denial Code(s)
How to Request a Claim Review
Submit claim reviews electronically by completing the online Provider Claims Reconsideration Form found at https://tricare.triwest.com.
The easy online form enables secure and efficient claims reconsideration submissions, eliminating the added tasks of printing and mailing the forms, saving you time and money!
The form can also be submitted by mail. Download and fill out TriWest’s Provider Claims Reconsideration Form found at https://tricare.triwest.com, and mail or fax it and all supporting documentation to:
TRICARE West Provider Correspondence
P.O. Box 2748
Virginia Beach, VA 23450
Fax Number: 1-866-852-1969
Providers must submit separate reconsideration requests for each disputed item within 90 days of TRICARE PRA/ERA date.
Please refer to TRICARE Operations Manual, Chapter 12, Section 3 to learn more about requesting claims review and appealable issues.
Fraud and Abuse
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.
An example of fraud, waste and abuse includes billing for services, supplies or equipment not furnished or used by the beneficiary.
Please refer to TRICARE Operations Manual, Chapter 13, Section 2 to learn more about TriWest’s responsibilities pertaining to fraud, waste and abuse.
Providers can report suspected fraud, waste and abuse in one of the three ways listed below:
- Call the Fraud Hot Line at 866-240-0382
- Mail your report to:
TRICARE West Program Integrity
P.O. Box 8430
Virginia Beach, VA 23450 - Fax your report to the Fraud Fax Number at 866-852-2009
The claim submission by a physician, supplier or their representative certifies that the services shown on the claim are medically indicated and necessary for the patient’s health and were personally furnished by the physician/supplier or furnished incident to his/her professional service by his/her employee under his/her immediate personal supervision, except as otherwise permitted by Medicare or TRICARE regulations.
For services to be considered as “incident” to a physician’s professional service, they must be rendered under the physician’s immediate personal supervision by his/her employee; be an integral, although incidental, part of a covered physician’s service; consist of commonly furnished in physician’s offices; and be included on the physician’s bills for services of non-physicians.
The claim submission by a non-institutional network provider/supplier further certifies that he/she (or any employee) who rendered services is not an active duty member of the Uniformed Services or a civilian employee of the U.S. Government (refer to 5 USC 5536).
Anyone who misrepresents or falsifies essential information to receive payment from federal funds may, upon conviction, be subject to a fine and imprisonment under applicable federal law.
Program Integrity
Program integrity is a comprehensive approach to detecting and preventing fraud and abuse. Prevention and detection are a result of functions of the prepayment control system, the post-payment evaluation system, quality assurance activities, reports from beneficiaries, and identification by a provider’s employees or TriWest staff.
DHA has a specific office to oversee the fraud and abuse program for TRICARE. The TRICARE Program Integrity Office analyzes and reviews potential fraud referrals (intent to deceive or misrepresent to secure unlawful gain) and cases of potential fraud.
Some examples of fraud include:
- Agreements or arrangements between the provider and the beneficiary that result in billings or claims for unnecessary costs or charges to TRICARE.
- Billing for costs of non-covered or non-chargeable services, supplies, or equipment disguised as covered items.
- Billing for services, supplies, or equipment not furnished or used by the beneficiary.
- Duplicate billings (e.g., billing more than once for the same service, billing TRICARE and the beneficiary for the same services, submitting claims to both TRICARE and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by TRICARE).
- Misrepresentations of dates, frequency, duration, or description of services rendered, or the identity of the recipient of the service or who provided the service.
- Practicing with an expired, revoked, or restricted license. An expired or revoked license in any of the United States or its territories will result in a loss of TRICARE-authorized provider status.
- Reciprocal billing (i.e., billing or claiming services furnished by another provider or furnished by the billing provider in a capacity other than billed or claimed).
- Violation of the participation agreement that results in the beneficiary being billed for amounts that exceed the TRICARE-allowable charge or negotiated rate.
The TRICARE Program Integrity Office also reviews potential abuse referrals (practices inconsistent with sound fiscal, business, or medical procedures and services not considered to be reasonable and necessary) and cases of potential abuse. Such referrals and cases of abuse often result in inappropriate claims for TRICARE payment.
Some examples of abuse include:
- Inferior quality care (does not meet accepted standards of care).
- Charging TRICARE beneficiaries rates for services and/or supplies exceeding those charged to the general public, such as by commercial insurance carriers or other federal health benefit entitlement programs.
- Failure to maintain adequate clinical or financial records.
- A pattern of claims for services that are not medically necessary, or, if necessary, not to the extent rendered.
- A pattern of waiver of beneficiary (patient) copayment, cost-share, or deductible.
- Refusal to furnish or allow access to records.
- Unauthorized use of the term “TRICARE®;” in private business, including in advertisements and website postings directed to TRICARE beneficiaries.
Providers are cautioned that unbundling, fragmenting, or code gaming to manipulate Current Procedural Terminology (CPT) codes as a means of increasing reimbursement is considered an improper billing practice and a misrepresentation of the services rendered. Such practice can be considered fraudulent and abusive.
Fraudulent actions can result in criminal or civil penalties. Fraudulent or abusive activities may result in administrative sanctions, including suspension or termination as a TRICARE-authorized provider. The TMA Office of General Counsel works with TriWest’s Program Integrity department and the TRICARE Program Integrity Office to deal with fraud and abuse. The DOD Office of Inspector General and other agencies investigate TRICARE fraud.
To anonymously report suspected fraud and/or abuse, you can take one of the following actions:
- Call the TriWest Fraud Hotline at 866-240-0382
- Send an e-mail to ProgramIntegrity@triwest.com (Do not include beneficiary names or Social Security Numbers)
- Send a fax to 866-852-2009
Please provide as much information as possible, including:
- Who committed the fraud
- When the fraud occurred (time frame)
- Where the fraud occurred
- Detailed description of the fraudulent activity
- Claim number(s) if known and applicable