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Welcome North Region Providers


NEW! Annual Pricing Updates: The following claim types are subject to the latest rate updates beginning with discharge dates of service on and after October 1, 2017: DRG, RTC, PHP and Inpatient Mental Health. These claims will be held temporarily until pricing updates are received from DHA. We expect the affected facility claims to be released by mid-November. We apologize for any inconvenience and thank you for your patience.

 

Are you ready? Learn about the upcoming changes to the TRICARE Program beginning January 1, 2018.

 

Reserve Component: Reserve Component Beneficiaries are entitled to TRICARE coverage while performing military duties or for medical conditions resulting from military service. If a patient record indicates this may be the case, please file your claim with TRICARE.

 

PGBA is a Certified Center of Excellence, awarded by BenchmarkPortal!  

 

Applied Behavior Analysis (ABA): BLS Certification enforced for ABA Providers.

 

Supervising or consulting physicians: Mental health counselor and pastoral counselor specialties require a supervising or consulting physician per TRICARE policy. The supervising or consulting physician information should be indicated in form locators 17, 17a (Tax Identification Number) and 17b (NPI) of the Form 1500 (02/12). Refer to the ‘National Uniform Claim Committee (NUCC) 02/12 1500 Claim Form Map to the X12 Health Care Claim: Professional (837)’ for loop ID and Segment/Data Element information.

 

Urgent Care Clinics: Beneficiaries should contact their PCM or family doctor first to best decide where and when to get urgent medical care.

 

TRICARE Appeal Rights: To submit a non-expedited reconsideration request to Health Net, specific instructions must be followed by the appropriate appealing party.

 

Outpatient Prospective Payment System (OPPS): Centers for Medicare & Medicaid Services (CMS) implements quarterly updates to OPPS. Information related to the October 2017 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.

  


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