 |
Date: 2/22/2010
Topic: Genetic Testing
Expected implementation date: 11/5/09
Refinement: EDI claims in with diagnosis, CPT4/HCPCS, HIPPS, RUG or revenue codes that are no longer HIPAA compliant will be rejected front end.
|
|
Date: 2/22/2010
Topic: Inpatient DRG
Expected implementation date: 9/25/09
Refinement: POA/HAC - Non-exempt inpatient DRG claims without a valid Present On Admission (POA) for date of admission on or after 10/1/09 will reject for invalid POA indicator.
|
|
Date: 2/22/2010
Topic: Genetic Testing
Expected implementation date: 9/17/09
Refinement: Genetic Testing codes 88384, 88385 and 88386 will reject as these codes are not FDA approved and not covered by TRICARE.
|
|
Date: 2/22/2010
Topic: ECHO
Expected implementation date: 9/3/09
Refinement: ECHO Cap Increase - Extended Care Health Option (ECHO) and Autism Demonstration services have been modified to increase the yearly benefit to $36,000 from $30,000 with an effective date of 10/14/08.
|
|
Date: 4/30/2009
Topic: Urinalysis by Dipstick
Expected implementation date:5/1/09
Refinement: Per the TRICARE Reimbursement Manual, separate reimbursement is allowed for urinalysis by dipstick billed in conjunction with an evaluation and management (E&M) CPT code when the date of service is October 1, 2008 or greater.
|
|
Date: 4/30/2009
Topic: Outpatient Prospective Payment System (OPPS)
Expected implementation date: 5/1/09
Refinement: Under OPPS, hospital outpatient services are paid on a rate-per-service basis that varies according to the Ambulatory Payment Classification (APC) group to which the services are assigned. Group services identified by HCPCS codes and descriptors within APC groups are the basis for setting payment rates under the hospital OPPS. TRICARE was mandated to adopt Medicare’s reimbursement rules when practical, which includes Medicare’s Prospective Payment System for reimbursement of hospital outpatient services. Please note that while TRICARE OPPS is modeled after the Medicare OPPS, differences in the two systems exist.
|
|
Date: 4/6/2009
Topic: Government No Pay List
Expected implementation date: 3/7/09
Refinement: The No Government Pay procedure code list was updated with an effective date of 3/11/09 per the TMA Web site.
|
|
Date: 4/6/2009
Topic: Annual CMAC Updates
Expected implementation date: 3/7/09
Refinement: FY2009 pricing updates for codes on or after date of service 3/1/09.
|
|
Date: 4/6/2009
Topic: ClaimCheck
Expected implementation date: 3/4/09; Effective TMA date was 10/1/08.
Refinement: ClaimCheck software was customized to remove the incidental reject R6CLA from procedure codes 81002 and 81003 when billed with certain E&M codes on the same date of service, per TRICARE Reimbursement Manual 89.
|
|
Date: 4/6/2009
Topic: Active Duty Service Member – Point of Service
Expected implementation date: 2/27/09
Refinement: Claims with a place of service 20 or 23, Revenue code 0450-0459, HCPCS/CPT code 99281-99285 for Active Duty Service Member claims will no longer route to MMSO or MCSC for emergency services.
|
|
Date: 4/6/2009
Topic: Active Duty Service Member - Authorizations
Expected implementation date: 2/27/09
Refinement: Active Duty Service Member claims will no longer route to MMSO or MCSC when the services were rendered by the following provider specialties: 01-General Practice, 08-Family Practice, 11-Internal Medicine, 37-Pediatrics, BE-Physician's Assistant.
|
|
Date: 4/6/2009
Topic: Injectable Drug
Expected implementation date: Effective date is 1/1/09
Refinement: The FY 2009 Injectable file was added to the system.
|
|
Date: 4/6/2009
Topic: BlueBook Replacement
Expected implementation date: 1/28/09
Refinement: The BlueBook Replacement File from First Data Bank was added to the system.
|
|
Date: 4/6/2009
Topic: Birthing Center
Expected Implementation date: Effective 4/1/09
Refinement: FY 2009 Birthing Center rates have been updated according to the TRICARE Reimbursement Manual (TRM 87.)
|
|
Date: 4/6/2009
Topic: Out of Jurisdiction Claims
Expected Implementation date: 1/9/09
Refinement: Discontinue provider notification letters for hard copy claims that are transferred by PGBA to the appropriate contractor.
|
|
Date: 3/25/2009
Topic: CPT code 90681-Rotarix Vaccine
Expected implementation date: Effective 2/6/2009
Refinement: CPT code 90681 has been removed from the government no pay list. Claims with a date of service on 2/5/2009 and after will pay. This code requires an NDC number.
|
|
Date: 7/25/2008
Topic: EDI PO Box Reject
Expected implementation date: 7/25/2008
Refinement: EMC / HIPAA professional and institutional claims must be submitted with a physical address. If a claim is submitted with only a PO Box as the billing and/or service/facility address, the claim will be returned to the submitter with the following reject message: NEED PROV PHYSICAL ADDRESS IN 2010 OR 2310. Professional claims submitted with HIPAA place of service 12, 14, 21, 22, 23, or 24 are excluded from this change. They will be accepted with a PO Box and no physical address.
|
|
Date: 7/25/2008
Topic: Immunizations
Expected implementation date: 7/25/2008
Refinement: Adminstration fees will reject when billed by a different provider other than the provider that billed the related immunization.
|
|
Date: 7/25/2008
Topic: Electronic Claim Transfer to WPS
Expected implementation date: 7/25/2008
Refinement: EDI claims will no longer reject on the front end when claims are out of jurisdiction (OOJ). Electronic claims that are OOJ for the West Region and TDEFIC will be automatically deleted and electronically transferred to Wisconsin Physician Services (WPS).
|
|
Date: 7/18/2008
Topic: EMC claims and NPI numbers
Expected implementation date: 7/18/2008
Refinement: Electronic claims that posted informational edits for invalid NPI
numbers will reject back to the provider front-end through the EDI gateway. The edit are:
NP2 - Invalid Attending Physician NPI
NP3 - Invalid Operating Physician NPI
NP4 - Invalid Referring Physician NPI
NP5 - Invalid Pay-To Provider NPI
NP7 - Invalid Service Facility Location NPI
|
|
Date: 7/18/2008
Topic: Physician Assistant acting as an assistant-in-surgery
Expected implementation date: 7/18/2008
Refinement: Assistant surgeon claims with a provider specialty for a Physician Assistant (PA) will receive an additional reduction from the allowable charge when acting as an assistant-in-surgery on claims with date of service May 1, 2008 or later. Calculation of the allowable is as follows: CMAC less 35% (PA rate), then less 84% (Assistant Surgeon Rate), then less any applicable provider negotiated discount.
|
|
Date: 5/23/2008
Topic: Cancer Clinical Trials
Expected implementation date: 5/23/2008
Refinement: Cancer Clinical Trials is a new program for beneficiaries enrolled April 1, 2008 and after. These claims pay based on regular TRICARE guidelines. Claims for patients enrolled in the Cancer Clinical Demonstration prior to April 1, 2008, will continue to process according to the demonstration guidelines.
|
|
Date: 5/1/2008
Topic: Government No Pay List
Expected implementation date: 5/16/2008
Refinement: Government No Pay List updated per TMA Web site.
|
|
Date: 5/1//2008
Topic: Ambulatory Surgery Center (ASC)
Expected implementation date: 5/2/2008
Refinement:Reimbursement is not allowed for a Revenue code in the 45X range and 0636 when submitted on an Ambulatory Surgical Claim (ASC) unless the HCPCS Code is a surgical procedure found in the range 10021-69999 and limited HCPCS level II codes (excluding fetal monitoring and venipuncture). Per TRICARE Reimbursement Manual, Chapter 9 Sect 1. Reimbursement is not allowed for Revenue codes in the 45X range when submitted with an E&M code on an Ambulatory Surgical Claim (ASC) unless it is a separately identifiable procedure performed using the appropriate modifier.
|
|
Date: 4/24/2008
Topic: Mammography
Expected implementation date: 4/25/2008
Refinement: Screening mammography services not covered when beneficiary is age 34 years or younger.
|
|
Date: 4/24/2008
Topic: Authorization Treatment Codes
Expected implementation date: 4/24/2008
Refinement: Home Health providers can use alpha-numeric authorization treatment codes in XPressClaim.
|
|
Date: 4/16/2008
Topic: Maryland Inpatient Mental Health
Expected implementation date: 4/18/2008
Refinement: Claims for the State of Maryland for inpatient mental health will be paid at the lesser of billed charges or the Maryland per day cap.
|
|
Date: 4/16/2008
Topic: Revenue Codes
Expected implementation date: 4/18/2008
Refinement: Revenue codes 360-369, 490-499, and 790-799 will not reject due to the revenue code and HCPCS codes not matching.
|