Your Practice's Missing Piece

Ins and Outs of TRICARE

As we all know, getting to know your insurances can be tricky! We always want the most efficient way to get our claims paid so here are some tips for you! In this article, we would like to focus on Tricare; specifically, Tricare South region.

When billing Tricare you should always follow some specific billing practices to get your claims paid efficiently and accurately. Bilateral claims for example, should be billed with the lines split by “LT”, “RT”.  All Tricare primary claims should be dropped to paper and submitted with the “Detailed Written Order”, or as Tricare calls it the “Certificate of Medical Necessity” (CMN). If you do not send the CMN with the claim when you bill it, there is a good chance it will be held up until the CMN is sent in.  If this does occur, you can quickly fax the CMN to (803) 462-3982 Attn: CMN.

An easy way to check claim status is the Tricare portal, It is simple to sign up, and easy to navigate. Once you obtain a log in, you can go to the “Claim Status” tab; fill in the sponsors ID, Birth date, and Office Location to check status. Once 15 days has passed since submitting your claim via mail, the claim should appear on your portal, if it does not, rebill the claim. The claim on the portal will state if it is pending, paid or denied. If the claim is pending, simply allow up to 30 days from the receival date before calling to see what is holding up the claim from payment. If it is paid, Tricare will provide you with the paid amount, check information and line item information. If the claim is denied, Tricare will provide you with the denial reason, and a detailed remit.

We’ve encountered a few common denial reasons with Tricare. One typical denial is missing the “Third Party Liability form”, this holds up claims until the patient fills out and returns the form to Tricare. This form can be located on the Tricare website if the patient misplaces it. Another common denial reason is missing the CMN as discussed above. Lastly, we’ve received many “maximum benefits have been reached” denials. This requires an appeal to be sent to Tricare with medical necessity explaining why item being provided is medically necessary.

Additionally, Tricare South will be changing soon. As you may know, Tricare is broken up into three regions, West, North, and South. On October 10th, 2017, Tricare North and South are going to be combining to become Tricare East. These changes will not affect much, Tricare’s guidelines will remain the same, although the Payer ID will change to “TREST”. WPS will be processing these claims for Tricare for dates of service October 10th, 2017 and after as they are going to be partnered as a subcontractor. Electronic claims are available for WPS Military Tricare East Region providers, they will have to complete the Provider EDI Self Registration form if they intend to use a clearing house. This also allows you to participate in Electronic Remittance Advice (ERA) to receive your payments via direct deposit.

In conclusion, the information provided above should help providers successfully submit their claims. Don’t forget to split your bilateral lines and mail your CMN with the claim, If there is any confusion or you do not know how to proceed with your claim, call the insurance company to follow up, they are great to work with, with a low hold time!