TRICARE Billing: Claims Deadlines, Regions and Contractors

TRICARE Filing, Prior Authorization and Portal

Appeal Levels

Top Denials from TRICARE

What Is the TRICARE Timely Filing Limit for Claims?

The TRICARE Operations Manual, Chapter 8, Section 3, says all claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided, or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.

The manual's own example: for service or discharge on March 22, 2015, the contractor must receive the claim no later than March 22, 2016.

A written request for benefits counts as a claim for deciding whether you filed on time, even if it is not on a claim form. The contractor must tell the claimant that only an approved claim form can be processed, and the claimant then has until the later of one year from service or discharge, or 90 days from the date the contractor gave notice. The manual says to submit on the CMS-1500, the CMS 1450 UB-04, or Defense Department Form 2642, as appropriate. A claim filed on time but returned for more information must be resubmitted by the later of one year after the services or 90 days from the date the claim was returned (32 CFR 199.7(d)(1)).

Which Exceptions to the Filing Deadline Apply?

A retroactive determination issued within one year of the date of service does not extend the one-year period, which stays binding. After an exception is granted the contractor may consider only services received in the six years before it received the request.

Who Is the TRICARE Contractor for My Claims, and Where Do I Submit?

TRICARE is managed in an East Region, a West Region and an Overseas Region, and each region has its own regional contractor. tricare.mil names Humana Military as the East Region contractor and TriWest Healthcare Alliance as the West Region contractor, and International SOS as the contractor for the Overseas Region.

A patient's region depends on where the patient lives, not where you are. tricare.mil offers a "What TRICARE region am I in?" tool that uses a ZIP code.

tricare.mil's East Region claims page says network providers must submit claims and can accept copayments and cost-shares. Beneficiaries cannot file institutional charges from network or non-network facilities. A non-network provider is either participating, accepting TRICARE payment and the TRICARE Maximum Allowable Charge as full payment, or non-participating, who may charge up to 15% more than the TMAC. If a provider is not TRICARE-authorized on the date of service, the East page says the claim will be denied.

Your facility's own location does not set the region. See our San Antonio guide for how a hospital there handles TRICARE next to Medicare and commercial payers.

How Does TRICARE for Life Work as Secondary to Medicare?

TRICARE For Life is wraparound coverage for people who are TRICARE-eligible and have both Medicare Part A and Part B. For Medicare-covered services, Medicare pays first, then sends the claim to the TFL claims processor, and TRICARE pays the provider directly for TRICARE-covered services.

In most cases the provider files the claim with Medicare and does not file separately with TRICARE. tricare.mil's TFL page orders payment when a patient has other health insurance (OHI). Employer-sponsored insurance through a current employer pays first, then Medicare, then TRICARE. Other insurance not based on current employment pays after Medicare and before TRICARE. TRICARE pays last in both cases. Rules for Medicare secondary payer and coordination of benefits decide the order, so verify it for each patient.

If the patient sees a Medicare nonparticipating provider, the patient may need to file the claim, and tricare.mil lists that among the cases where beneficiaries file. For Medicare payer rules, see the Medicare billing guide.

What Are the TRICARE Appeal Levels and Deadlines for a Denied Claim?

If a claim is denied because of incorrect filing, tricare.mil says to correct the error and resubmit it to the claims processor. If you believe it was inappropriately denied, in whole or part, you or another appropriate party can file an appeal. Under 32 CFR 199.10, a participating provider can appeal, but a nonparticipating provider is not a party to the initial determination and may not appeal.

The regulation says the contractor normally issues its reconsideration determination within 60 days of receiving the request. A request is filed on the date it is mailed and postmarked. tricare.mil separates factual appeals, for denied or stopped payment, from medical necessity appeals, for denied pre-authorization, from pharmacy appeals and Medicare-TRICARE appeals. Your regional contractor sends the first decision, and the denial letter tells you how to file.

Check the amounts in dispute before you appeal. If a reconsideration determination is for less than $50, the regulation makes it final. Read CO-29 for filing-limit denials and CO-16 for correctable claim errors.

What Happens When TRICARE Asks for Money Back?

TRICARE recovers erroneous payments by a written demand, and you have 90 days from the date of the first demand letter to ask the contractor for an administrative review. 32 CFR 199.11 lists examples of erroneous payments: claims for people not eligible, claims for non-covered services or supplies, claims where another insurer's payment reduces TRICARE's share, and participating-provider claims where payment first went to the beneficiary by mistake.

Put the demand date on your calendar the day the letter arrives, send the review request in writing with the claim number and your reason, and check the amount against the appeal thresholds above. A beneficiary or participating provider can also use the appeal procedures in 32 CFR 199.10 for an administrative appellate review.

How Do I Check Eligibility and Submit Prior Authorization for TRICARE Members?

Prior authorization and referral rules depend on the patient's TRICARE plan and are handled by the regional contractor, so call Humana Military in the East or TriWest in the West before the visit. Eligibility is recorded in the Defense Enrollment Eligibility Reporting System, or DEERS, the database where a person must be registered to get TRICARE.

tricare.mil's appeal page describes a medical necessity appeal as the one used when pre-authorization for care is denied because it is not medically necessary, and says the regional contractor sends that decision. Keep the denial letter, because it explains how to file.

Our prior authorization service and eligibility verification service cover how those checks sit before the visit.

How Do I Dispute an Out-of-Network Underpayment from TRICARE?

tricare.mil routes payment disagreements to the appeal levels above, with a factual appeal for denied payment or payment that was stopped. Its claims and appeals pages do not describe open negotiation or federal IDR.

For non-network providers, the East Region page says a participating provider accepts the TMAC as full payment and a non-participating provider may charge up to 15% above it. The No Surprises Act hub and our out-of-network billing and IDR service cover the federal process.

Which Portal or Clearinghouse Do I Use with TRICARE?

Claims go to the regional contractor for the patient's region, or to the TFL claims processor after Medicare for TRICARE For Life. The tricare.mil Filing Claims page links regional claims pages for East, West and overseas, plus a TFL claims portal.

For the claims rules that apply to all payers, see timely filing limits by payer. For the contractor's electronic payer ID, ask the regional contractor.

Where Does Nucleus Align Fit?

When TRICARE denials come back near the one-year deadline, our denial management service works them, and the payer guides hub lists the other payers we cover.