Please Note: The website information and material is for Dates of Service prior to 1/1/2018. If you are looking for information for Dates of Service on or after 1/1/18, please go to the new contractor website: Humana Military for the TRICARE East Region.
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!
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.
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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