Tricare Denials

TRICARE

Payer Info:

 Website: www.myTRICARE.com

o Login Info: O:\Insurance Websites

 Phone Numbers:

o Tricare: 1‐877‐988‐9378

 Fax # 1‐855‐831‐7041

o Tricare for Life: 1‐866‐773‐0404

 Fax # 608‐301‐3100

Important Payer Info:

o Rule of thumb – if the EOB lists a patient responsibility then we can bill the patient.

o If the EOB doesn’t indicate patient responsibility, the balance needs to be adjusted.

 Tricare is always the secondary payer to all other insurance, except Indian Health Service (IHS)

and Medicaid.

 Timely filing:

o Claim submission: 1 year from DOS.

o Appeals: 90 days from EOB denial

 Inpatient Place of Service denials/issues: Please call payer and inquire if this should be covered under the inpatient authorization, as the professional care provided occurred during the patient’s authorized inpatient stay.

o If you see POS 21 on the HCFA, please review for an authorization within EPIC.

 Example of inpatient authorization # 400843605 / 100173818 valid from 5/23 –

5/25.

o If you don’t see an authorization within EPIC, please use an advanced filter to search for the DX’s billed to see if we’ve been paid on other claims during the same visit.

 If same DX’s have been billed and paid, request for claim to be sent back for review.

Common Denials:

CO 185 – This denial means the providers need to register with Tricare (separate from enrollment). To work this denial:

 Call Tricare, and verify if the provider is registered with this payer.

o If provider is registered, request for claim to be reprocessed.

 If provider is not registered with Tricare, please transfer to WQ 17591 for registration to be completed.

CO18/N522 – Duplicates – This denial are for CPT’s billed more than once for the same DOS by the same provider. To work this denial:

 Sort claims by DOS to verify how many times the CPT in question was billed, and verify if there are any modifiers to distinguish separate service.

 Review to see if payment was retracted or refunded.

 Review the EOB to find the original denial in case claim was CC’d or retro’d.

 Check undistributed credits to see if payer paid, and payment was undistributed. If payment matches, DOS, provider, CPT & Modifier, and billed amount – distribute the payment.

 Check medical records to confirm we are billing the correct number of procedures.

o If the Medical records DO NOT support the extra service, and the claim is truly a duplicate – please void the charges.

o If the Medical records support the billing and modifiers billed, call the payer and advise them of the repeat procedures and have them reprocess the claim.

 If Payer advises they need medical records to support the billing, ask if we need can just send in medical records or if we have to appeal; ask if there is a required form that needs to be included for medical records submission or appeal; ask if the medical records or appeal can be faxed or if they have to be mailed (be sure to note the details for each option in the notes).

MA04‐ Can’t make payment without Prime EOB – This denial results when the payer hasn’t received the primary EOB. To work this denial:

o If there is other insurance listed, check for an EOB from the other insurance.

 If we have an EOB with a valid denial, fax copy of EOB to Tricare with the claim #

typed out on the EOB (for payer to easily reference). Fax # 1‐855‐831‐7041.

 If we don’t have an EOB from the other insurance, call the other payer and request a copy or print from payer website.

^{o If the other insurance is found in Epic and has been verified, but claim has never been}

billed to the primary insurance – please select Default Coverage in Edit Visit Coverage to bill the proper insurance.

^{o If there is no other payer info found in Registration:}

 Call the payer to see if they will provide us the other payer info.

 Verify the patient’s other coverage, and update registration.

 If the account reactivates and we still don’t have the other payer info and it’s been 14 days since a smart text letter has been sent, NPR balance to self‐pay.

CO 97/M19 and CO 231 – These denials are bundling denials from the payer. To work this denial:

 Check Encoder Pro/Code Correct, and verify the CPT’s billed on the DOS for possible bundling issues.

 Call payer and verify what CPT is bundled to the primary CPT.

 Once bundling issue has been confirmed, Checked in NATIONAL CODE CORRECT,check whether it is a valid denial or invalid.If it is a valid denial,call the payor and  asked them to reconsider the decision and  if  rep refused,appeal them with appropriate MR.

N545 – PMT reduced not Eprescribed. This denial is seen with insurance crossover issues from

Medicare. To work this denial:

 Call payer and verify if they have received the cross over claim from Medicare.

o If no claim on file, resubmit the claim to Tricare.

o If the claim is on file, verify if they have received the primary EOB (crossover claim may have crossed over without one).

 Verify with the payer if we can fax this info, and note the fax # in your notes.

 If patient has tertiary insurance, review the primary and secondary EOB. If you Tricare advised they received the claim but denied CO23 – this means the previous insurance paid more than what Tricare would have paid. Please adjust remaining balance with CO23.

PR31 – Denied patient can’t be identified as our insured. This denial results when we bill the wrong ID

or patient name on claim. To work this denial:

 Verify on the website if we have the correct ID #, and verify if the patient is truly eligible. (Please be aware Tricare requires either the Sponsors SSN 9 digits to be billed or we will need the benefits ID # including the dependent code – example 0061368800 followed by 00,01, or 02).

o If you enter the details on the website, and nothing pulls up ‐ please call the payer to verify the patient’s coverage.

o If the patient’s benefit ID # ends in 00 or 01, and the DOB is for a child, please try entering the benefit ID # with a 02‐09; this will match the patient by their DOB. Once you have identified the correct dependent code, update Registration with the proper benefit ID #, and rebill the claim.

 If the primary insurance has paid before Tricare, and VFO is used to bill the proper insurance the primary payment will go undistributed. Please redistribute the payment, and then NRP the claim to bill Tricare with the correct ID #.

^{o If you have verified on the website the patient is eligible and we have the correct ID #,}

or you have called the payer and have also verified this info – please verify why they denied the claim if we have the correct info. Request for the payer to reprocess the claim; if the claim denied for another reason, please work the updated denial.

OAL6 – Provider allowed/paid amount from prime coverage. This denial is worked similar to the MA04 denial. To work this denial:

 Verify Tricare in Registration that this payer is listed as the payer of last resort (should not be prime unless there is no other coverage).

o If there is a primary insurance listed with Tricare, please update the filing order to show

Tricare as secondary and bill the proper insurance.

o If we don’t have any other insurance in Registration, please call the payer and verify who the other coverage is. If payer will not release that information, please transfer account to WQ 30751 for a phone call or smart text letter to be sent to patient.

 If there is other insurance on file, and they have paid. Call Tricare, and verify if they have the EOB. If they don’t, please fax the prime EOB to them at 855‐831‐7041 for Tricare. Tricare for Life plans, please fax to 608‐301‐3100.

o If primary insurance denied the claim (and is not patient responsibility), please NRP the claim back to the primary insurance for the team to work the denial.

Blanks – The blanks are for no response from the payer. To work this denial:

 Review claim to see if claim has ever been CC’d or retro’d, and review the EOB.

 Check Registration to see if patient has other coverage, because Tricare is always secondary to all other payers except for IHS.

o If patient has other coverage, verify patient’s eligibility and if patient is eligible, bill the proper coverage using the Default Coverage option in Edit Visit Coverage.

o If there is no other insurance on file, follow the next bullet point.

 If we don’t have a response from the payer, check the Insurance Timely Filing at O:\AR Team

and verify if we are within the timely filing limit. If patient is eligible and we are within the timely guidelines, call the payer and verify if they have record of the claim.

^{o If payer advises they DO NOT have record of the claim, verify if they accept EDI claims. If}

EDI is accepted, resubmit the claim.

 If payer does not allow EDI ask if we can fax claim and note the fax # in your notes and fax. Defer claim for 30 days.

 If payer advised claims must be mailed, transfer account to WQ 525 with detailed notes.

CO 96 – Non‐covered services. This denial will always require a phone call to the payer, to verify the true denial.

 Ask the payer why the services were denied as non‐covered?

 Ask if the procedure/CPT is an exclusion of the patient’s benefits?

o Ask if the patient is responsible for the non‐covered services, if the procedure is an exclusion of the patient’s benefits.

 Adjustments are taken as a last resort; we need to verify why the services truly denied before adjusting or NRP’ing the balance to self‐pay.

CO 242 – Services not provided by network/PCP. This denial is generally seen when the patient receives treatment from a non‐participating/non‐contracted provider. If you see this ANSI code on the EOB, please proceed with the following:

 Review the EOB to see if there is any patent responsibility. If there is patient responsibility, adjust the remaining amount as CO45, leaving only the patient responsibility.

 If there is no patient responsibility listed on the EOB, call he payer to inquire the details regaring the denial and if it’s related to provider enrollment.

o If payer confirms the denial is provider enrollment related, transfer to WQ 17591.

N245 – Incomplete/invalid plan info from other insurance.

 Review the EOB to see if there is any additional information that can be given.

 Call the payer to find out what information is incomplete, and what is needed to process the claim.

 If payer advises they don’t have the prime EOB, or the EOB doesn’t match the info we are giving over the phone, please ask for a fax number and send them the updated EOB with reference to the patient’s ID # and claim number.

PR165 – PMT denied/rcv’d, referral absent or exceeded.

 Call the payer and erify if the have record of a referral on file

 If payer advises no referral on file, ask them if they allow retro referrals and who is responsible for sending in the info

o If payer advises retro referrals are allowed, ask the payer if they can reprocess the claim or if they need any additional info from us to reprocess the claim.

 If the payer advises there is a referral on file, ask if the claim can be sent back for reprocessing.