PROVIDERS

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Welcome North Region Providers


Annual DRG Updates: If you submit inpatient facility claims or low volume mental health claims, they will be subject to the latest DRG rates beginning with discharge dates of service on October 1, 2014, and after. These claims will be held temporarily until the pricing updates are completed. We expect the affected facility claims to be released by mid-November. We apologize for any inconvenience and thank you for your patience.

 

Revenue Codes/HCPCS: Most revenue codes are now required to be billed with a valid HCPCS code, effective immediately.

 

Health Net and PGBA are proud to announce that once again our call center operations have been certified as a Center of Excellence by BenchmarkPortal. Read about it here.

 

Applied Behavior Analysis (ABA): Learn the latest TRICARE coverage for ABA Services.

 

Revised Professional Claim Form: Beginning April 1, 2014, only professional claims submitted on the Form 1500 (02/12) will be accepted.

 

Outpatient Prospective Payment System (OPPS): Centers for Medicare & Medicaid Services (CMS) implements quarterly updates to OPPS. Information related to the October 2014 update is available directly from CMS. Please note: Medicare specific coding requirements must be followed (with the exception of DHA developed APCs) in order to receive TRICARE reimbursement under the OPPS.

 

Sole Community Hospitals: Important information regarding reimbursement.

 

Abortion Claims Coverage: Details about submitting abortion claims.

 

XPressClaim: Remember that you can submit corrected claims through XPressClaim too!

 

EDI Submitters - Prevent your TRICARE claims from rejecting with the Invalid Member ID (H65) edit. 

 


 

 

Our Prime Partner

Click here to go to our Prime Contracting Partner's website to find other helpful tools.

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