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Electronic Data Interchange (EDI) Billing Tips


Please use the below references when billing TRICARE. More details are available in the HIPAA Companion Guides for billing TRICARE. Please review our Electronic Media Claims (EMC) Handbook.

Top Ten Edits

Check out the TOP TEN EDITS and Solutions for TRICARE claims submitted in 837 I/P formats 

 

Billing TRICARE as a secondary payer when submitting 837 (HIPAA) format  Form 1500 (02/12) claims
(Patients who have Medicare are not billed to this payer)

  • Loop 2320 Segment SBR01 = P 
  • Segment AMT01 = D
  • Segment AMT02 = Amount Paid by Other Provider
  • Loop 2320 for Claim Level or 2430 for Line Level

  • CAS= Adjustment reason codes with amounts used to calculate allowed amounts based on the CAS codes from the prior payer’s payment information

  • Patient responsibility will be shown as Category Code PR in CAS01


Other Health Insurance (OHI) for Facility Claims (UB04)
(Patients who have Medicare are not billed to this payer)

  • Loop 2320 Segment SBR01= P 
  • Segment AMT 01= D
  • Segment AMT 02= Amount Paid by Other Provider
  • Loop 2320 for Claim Level or 2430 for Line Level

  • CAS= Adjustment reason codes with amounts used to calculate allowed amounts based on the CAS codes from the prior payer’s payment information

  • Patient responsibility will be shown as Category Code PR in CAS01

NDC Numbers

 

Please reference the home infusion therapy billing guidelines. 

 

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 XX5 is invalid and will not pass front-end rejects.

 

Corrected Claims for Professional claims (Form 1500 02/12)

  • 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

 

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:

  • Form 1500 (02/12) 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 from the 2010AA loop in the HIPAA EMC format. If the service address is different, this will map from 2310C loop in the HIPAA EMC format.
  • UB04 Post Office boxes should only be in block FL2.  FL1 requires the physical address. This maps from the 2010AA loop in the HIPAA EMC format. The 2011AB loop maps to FL1 if the service address is different from the address in 2010AA.

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