Claims
You can check the status of your claims online by logging in to our Secure Portal. In order to view status information, the National Provider Identifier (NPI) on your www.tricare-west.com account must match the billing NPI on the claim.
If you do not have a www.tricare-west.com account, use the automated self-service tools at 1-844-866-WEST (1-844-866-9378).
There are specific guidelines regarding TRICARE and other health insurance. Visit the How TRICARE Works with Other Health Insurance page.
You should receive a remittance adivce which will explain why a claim was denied. You can view your remittance advice online (log in required).
Before delivering care, network providers must notify TRICARE patients if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services. The Request for Non-Covered Services form can be used to document the specific services, dates, estimated costs, and other information. If the beneficiary does not sign a Request for Non-Covered Services form or equivalent, you are financially responsible for the cost of non-covered services you deliver.
Hold Harmless Policy for Network Providers
A network provider may not bill a TRICARE beneficiary for services not covered, except in the following circumstances:
- If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary.
- If the beneficiary was informed that services were not covered and agreed in advance and in writing to pay for the services.
Hold Harmless Policy for Non-Network Providers
Non-network providers should also inform beneficiaries in advance if services are not covered. Although not required, non-network providers are strongly encouraged to use a Request for Non-Covered Services form or their own office equivalent to document payment agreements.
Claims can be recouped for various reasons, including, but not limited to:
- Loss of eligibility
- Claim processed without other health insurance information
- Erroneous payment of a non-covered service
- Review of the medical records does not show medical need for the service
The recoupment reason is listed on the recoupment letter or on an attached list of claims. If the recoupment is because the service is not covered under TRICARE or not medically necessary, then appeal rights are given in the recoupment letter.
XPressClaim allows you to submit claims online and often receive instant payment results. Visit our XPressClaim page to learn more.
Online claims submissions allow you to receive faster payments and reduce errors. Visit our Claims Submission page to learn more.
TRICARE network providers must file their patients’ TRICARE claims with Health Net Federal Services/PGBA, even if a patient has other health insurance (OHI). All network provider claims must be filed electronically.
Non-network providers are encouraged to take advantage of the electronic claims features available through Health Net Federal Services and PGBA.
For more information, view our Claims Submission page.
Medicare Bonus Payments: Physicians (MDs and DOs), podiatrists, oral surgeons, and optometrists who qualify for Medicare bonus payments in Health Professional Shortage Areas (HPSAs) may be eligible for a 10% bonus payment for claims submitted to TRICARE. The only mental health care providers who are eligible for HPSA bonuses are MDs and DOs.
You may visit the Defense Health Agency's website for current TRICARE allowable charges, also referred to as CHAMPUS Maximum Allowable Charges (CMAC).
Non-participating TRICARE non-network providers can bill up to 115 percent of the CMAC.
CPT is a registered trademark of the American Medical Association. All rights reserved.
PGBA’s proprietary electronic claims system for filing secondary claims with Medicaid can assist in facilitating the flow of claims between TRICARE and Medicaid, and significantly reduce the amount of paperwork required when large batches are submitted. Contact PGBA's EDI help desk at 1-800-259-0264 for more information.
When submitting time units for anesthesia, include the number of minutes on electronic claims or start and stop times on paper claims.
Uniformed Services identification cards contain two numbers assigned by the Department of Defense (DoD):
- The DoD Benefits Number (DBN), which is an 11-digit number found on the back of the ID card that can be used to verify eligibility and file TRICARE claims.
- A DoD ID number, which is a 10-digit number found on the front of the ID card. The 10-digit DoD ID number should not be used when submitting TRICARE claims. If the DoD ID number is used, the claim will be denied or returned.
If your office requires the Social Security number (SSN) of the insured for claims filing, make sure the SSN used is the insured service member's and not the family member’s.
TRICARE claims must be submitted to the TRICARE region in which the beneficiary resides in or is enrolled, even if the care was received in a different region. If you provide health care services to a TRICARE beneficiary who resides in or is enrolled in the West Region, the beneficiary will pay the applicable cost-share, and you will submit claims to Health Net Federal Services, LLC.
Note: TRICARE beneficiaries are instructed to receive all routine care, when possible, from network providers in their designated regions. However, if a TRICARE Prime beneficiary does not receive a referral, when required, for out-of-region care, claims will be paid under the point-of-service (POS) option.
