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Electronic Claims Filing & EDI


TRICARE network providers must file 100% of their TRICARE claims electronically. We encourage non-network providers to take advantage of this feature as well. Electronic claims are faster than paper claims, so you get paid faster. Electronic filing also saves you time and money.

 

Go 100% electronic with:
North Electronic Funds Transfer (EFT)

XPressClaimSM  

Electronic Remittance Advice (ERA). Find information about the Remit Easy Print software.

 

 

Which electronic claims option is right for you?

  • Submit no more than 150 claims a month?   XPressClaim is your best option. You can enter your claims right on the Internet, and it's fast and free!  
  • High volume of TRICARE patients? Submit claims to other payers as well as TRICARE? Here's a list of approved vendors/clearinghouses. See the EDI Vendor/Clearinghouse Disclaimer.
  • Can you create an ANSI electronic file and upload via asynchronous telecommunications? Batch processing is available through our EDI Gateway mailbox system.  Contact us to start the enrollment process.

 

Have you filed an Electronic Date Interchange (EDI) provider Trading Partner Agreement with us? 

Download a copy of the HIPAA EDI Provider Agreement.

 

Download the Clearinghouse/Direct Submitter Trading Partner agreement.


Please note:If your clearinghouse is Emdeon (formerly WEBmd), please verify that your software application has the correct Payer ID. The North Region Payer ID is 57106. The South Region Payer ID is 61125. Please call your Emdeon representative if you have questions (1-877-469-3263). PGBA's published Payer ID for TRICARE claims is 38520. Please contact your clearinghouses or vendors to find out if they are using a different Payer ID for PGBA.

 

Health Insurance Portability and Accountability Act (HIPAA) Companion Guides

HIPAA EDI Provider Agreement

276/277 Healthcare Claim Status

835 Healthcare Claim Payment/Advice (Find information about the free  Remit Easy Print software for 835 Healthcare Claim Payment/Advice).

270/271 Healthcare Eligibility

837 Institutional Healthcare Claim

837 Professional Healthcare Claim

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Provider File Maintenance

Please verify that PGBA, LLC has the correct address on file for each location and/or specialty! Sign In and select the Provider File Maintenance tab. This will ensure there aren’t any gaps between your enumeration strategy compared with PGBA’s internal legacy identifiers as well your TRICARE payments. Once you’ve verified your addresses, follow the guidelines below:

  • CMS 1500 If the billing address (block 33) is not the physical address (where services were rendered), please put the physical address in block 32.  This will map to the 2310D loop in the HIPAA EMC format.
  • UB04 Post Office boxes should only be in block FL2.  FL1 is for the physical address. This will map to the 2010AA loop in the HIPAA EMC format.

 

Tips for billing TRICARE as a secondary payer when submitting 837 (HIPAA) format CMS 1500 claims:

  • Loop 2320 Segment SBR01 = P  (This is block 11D on the CMS 1500)
  • Segment AMT01 = D
  • Segment AMT02 = Amount paid by other payer. (This is block 9A on the CMS 1500)
  • Segment AMT01 = B6
  • Segment AMT02 = amount allowed by other payer. (This is block 19 on the CMS 1500)

 

Tips for billing TRICARE (More detail is available in the HIPAA Companion Guides):

Other Health Insurance (OHI) for Facility Claims (UB04)

  • Loop 2300
  • Segment HI01-1= BE
  • Segment HI01-2 = 44 and HI01-5 = amount allowed by other insurance (This is block 39 A, B, or C on the UB04 form)
  • Loop 2320
  • Segment AMT01= C4 and AMT02= amount paid by Other Health Insurance  (This is block 54 on the UB04 form)

 

NDC Numbers

  • Loop 2410 LIN segment when sending NDC numbers that correspond with certain J codes. Use 2400 SV103 to indicate package (UN) or unit (F2) pricing.

 

Corrected Claims for Facility Claims (UB04)

  • Loop 2300
  • Segment CLM05-3 = 7
  • Segment REF01= F8 and REF02 = 13 digit original claim number; no dashes or spaces
  • Facilities cannot bill late charges prior to having the original claim process. Bill type 135 is invalid and will not pass front-end rejects

 

Corrected Claims for Professional claims (CMS-1500)

  • Loop 2300
  • Segment CLM05-3 = 7
  • Segment REF01= F8 and REF02 = 13 digit original claim number; no dashes or spaces

 

Resource sharing claims

  • The contract type code must equal '09'
  • The reference Identification must contain the MTF/PPO ID
  • Loop 2300, the CN1 Segment needs to be present
  • Loop 2300-CN101  (Contract type code) = 09
  • Loop 2300-CN104 (Reference Identification) = MTF ID
  • The MTF/PPD ID, in the current format is located in DAO, field 13

 

Top Ten Edits

TOP TEN EDITS and Solutions for TRICARE claims submitted to PGBA, LLC in 837 I/P formats 

 

EDI Vendor/Clearinghouse Disclaimer

The Vendor/Clearinghouse list provides contact information about software vendors whose TRICARE Electronic Data Interchange (EDI) capabilities have been approved by PGBA, LLC. Vendors must be approved through the TRICARE EDI testing process or have at least one provider who submits live TRICARE claims electronically through their system.

We provide this list of vendors solely for your convenience and not as a recommendation by BlueCross and BlueShield of South Carolina, PGBA, TRICARE or the Health Care Financing Administration. Providers and vendors must make specific financial and service arrangements between them. PGBA will not be a party to any such arrangement. The listing is updated periodically and is subject to change between publications.


Didn't find the answer you need?

Call the TRICARE EDI Help Desk for the North Region at 1-877-334-2524


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