Easy Ways to Reduce Your Workload and Receive Faster, More Accurate Payments

Providers can take some simple steps to expedite the processing of their TRICARE West Region claims, reduce time spent on tracking the status of submitted claims and eliminate the need to submit duplicate or tracer claims.

First, take advantage of our newest enhancements on www.triwest.com, our secured provider web portal. As a registered provider, you can take advantage of self-service functionality including:

• Confirm beneficiary eligibility and benefits
• Check status of referrals and authorizations
• Update consult tracking feedback reports
• Check the processing status of submitted claims
• View detailed Explanation of Benefits (EOB) for processed claims

Next, if you are not already submitting claims electronically, as a registered user, you can submit your professional and institutional claims online and receive real-time processing results. Currently, claims are being processed within the following timeframes:

• 71% of clean claims submitted online are processed immediately (a clean claim does not contain a defect requiring investigation or development prior to adjudication)
• 97% of clean claims submitted online are processed in 15 days or less
• 99.7% of all clean claims are processed in 30 days or less

Lastly, second submissions and tracer claims can delay claims processing, impact the accuracy of claims payment and cost your practice valuable time. Providers can help avoid these problems by allowing at least 30 days from the date the claim is received at WPS before generating second submissions or tracers. This timeframe allows WPS time to receive the claim from your office or billing service, time to process all clean claims, and time for U.S. Mail delivery of your payment.

There are other time elements that can affect the timeliness of your receiving a claims payment, including:

• The time it takes to generate a claim and send to WPS. If you use a billing agency or clearinghouse, you can verify timely receipt of your claim on www.triwest.com. If time differences are substantial, you may want to verify with your biller as all claims carry the date we receive them electronically (or on paper).
• The time it takes for delivery and processing of the claim by your billing agent or clearinghouse
• You’re submitting your claims electronically to your clearinghouse, but your clearinghouse could be dropping your claims to paper and mailing them to WPS if there are any electronic submission problems without your knowledge. You can determine if this occurring by looking at the TriWest claim number. If the claim number includes the numbers 000 or 300 in the sequence, the claim was received on paper. The format for the 14-digit claim number is:
  • The first four digits = the year claim was received
  • Next three digits = the Julian date claim was received (Each day of the year has a number 1-365; e.g., February 1 = 032)
  • The next seven digits are the sequence:
    • If the first digit of the sequence is a 0, zero, it denotes a paper claim
    • If the first digit of the sequence is a 3, it denotes a paper claim scanned through Optical Character Recognition (OCR)
    • If the first digit of the sequence is a 4, it denotes a claim submitted online at www.triwest.com
    • If the first digit of the sequence is a 9, it denotes an electronically submitted claim
• The time it takes to receive a check and update your accounts receivable system

In addition, some providers may continue to count the time that the original claim was submitted to the primary payer or from the last date of service on the account as the submission date to WPS when TRICARE is the secondary payer. Due to the high proportion of secondary payments involved in TRICARE compared to other programs, WPS often receives a tracer claim from a provider at the same time that the initial claim is received showing the primary payer information. This results in increased denials due to duplicate claims and additional work for your office.

Here are some helpful hints to allow for accurate processing on the first submission:

1. The beneficiary’s Social Security number (SSN) cannot be used when filing a TRICARE claim. TRICARE requires the use of the sponsor’s (service member’s) ID because all claims must conform with the information in the Defense Enrollment Eligibility Reporting System (DEERS) (The exception is for a beneficiary who is divorced from the sponsor, but was married to the sponsor for at least 20 years and remains eligible for TRICARE; in this instance, the individual should use their own SSN). All TRICARE beneficiaries have a military identification card, which provides the Sponsor number.
2. If the beneficiary has other health insurance (OHI), please use the name of the plan and not the employer. It is best to indicate "ABC Health Plan" rather than the name of the employer, "XYZ Company." If employer names or insurance supplements that are not actually primary carriers appear on the claim, TRICARE requires denial of the claim while review for OHI is performed.
3. Submit anesthesia claims with the time units. Please use the industry standard of 15 minutes for each unit. (60 minutes equals 4 units). If we see units on anesthesia claims, we will assume they are time units as outlined above. The system adds the base units using standard anesthesia guidelines. All modifiers should be added using either the P1-P6 series or the 99XXX series outlined in the CPT manuals.
4. Claims with only a V70.0 diagnosis will be denied. In order to establish medical necessity and process the claim according to TRICARE criteria, a clear, specific diagnosis should be used; however, a "rule out" diagnosis is also acceptable. Laboratories should bill for the "rule out" diagnosis if a specific diagnosis is not listed.
5. Bill the appropriate preventive diagnoses. TRICARE does not cover routine care, such as sports physicals, but does pay for certain preventive care, such as mammograms. The additional of accurate ICD-9 codes will assist in proper processing.
6. Providers who separate services performed on the same day for the same rendering provider on separate claims are considered to be unbundling the services. All claims for the same date of service for the same beneficiary in the same place of service should be submitted together.
7. Frequent and inappropriate use of modifiers "25" (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or "59" (distinct procedural service) could result in review by TriWest’s Program Integrity department. Use of these modifiers may be appropriate when applied using current CPT manual guidelines.
8. Outpatient hospital units for Revenue Codes 360-369 or 490-499 must include the CPT/HCPCS code of the surgery. If the number of units is more than one and the surgery can only be done once on a single day, the claim will be denied requesting correction.
9. TriWest uses Medicare guidelines for "Assistant Surgeon." Please note that TriWest does not pay for the use of Registered Nurse First Assistants. If the care was done in a teaching hospital, the modifier &lsquo82’ must be used if there were no interns or residents available to perform the services. Otherwise, if the services were performed in a non-teaching hospital, please use modifier &lsquo80’.
10. If the beneficiary has Medicaid, please use Medicaid rather than the name of the state Medicaid plan. For example, Wisconsin Physicians Service (WPS) may not have a record of the name of each state’s Medicaid program and may request additional information before the claim can be processed. Therefore, it is best to indicate "Medicaid" rather than the name of the state’s Medicaid program.

For additional information on becoming a registered provider, submitting your claims online, and signing up to receive Electronic Remittance Advices (ERA), please refer to the Provider Connection area of www.triwest.com, or call 1-800-782-2680 (EDI Help Desk). You also can refer to a recent article on ERA that shows you how ERA can reduce your paperwork.