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Electronic Claims Filing & EDI


Find ICD10 preparation and ICD-10 Implementation FAQs information.

 

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

 

HIPAA 5010- All HIPAA-covered entities must be fully compliant with all of the upgraded transaction standards for ASC X12 Version 5010 by July 1, 2012. After July 1, 2012, all transactions that fail to meet the standards of version 5010 will not be accepted and will reject back to the submitter.


 

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.

 

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 the approved vendors/clearinghouses. 
  • Can you create an ANSI electronic file and upload via asynchronous telecommunications? Batch processing is available through our EDI Gateway mailbox system. View the Gateway user manual  to see if this option is right for you. Download the Electronic Data Interchange (EDI) forms.

 

Have you filed an Electronic Data 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 the EDI Vendor/Clearinghouse Disclaimer.

 

PGBA Payer IDs for TRICARE

Please contact your clearinghouse or vendor to make sure they are using the correct Payer ID for the TRICARE regions listed below. They may have a proprietary ID for you to use prior to submitting the claims to PGBA.

 

North Region Payer ID: 57106

 

South Region Payer ID: 61125

 

West Region Payer ID: 99726   

 

Note: If your clearinghouse is Emdeon (formerly WEBmd), the West Region payer ID is SCWI0 for professional claims; 12C01 for institutional claims. Please call your Emdeon representative if you have questions (1-877-469-3263).
 
If region is unknown, default to payer ID below:

 

 

PGBA's TRICARE Payer ID: 38520

 

Electronic Data Interchange (EDI) Billing Tips

Find information & tips to help with your EDI billing.

 

Companion Guides

276/277 Health Care Claim Status Request and Response

270/271 Health Care Eligibility Benefit Inquiry and Response

835 Health Care Claim Payment Advice

837 Health Care Claim Institutional

837 Health Care Claim Professional

 

 

Didn't find the answer you need?
Call the TRICARE EDI Help Desk for South Region at 1-800-325-5920, option 2. You may also send an e-mail to edi.tricare@pgba.com.

 

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

XPressClaim ®

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

 

 


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