Buy-and-Bill Reimbursement of Spravato

February 16, 2024

TRICARE recently updated language to clarify the billing procedures for the reimbursement of Spravato ® (esketamine) nasal spray.

 

According to the Food and Drug Administration (FDA) labeling, Spravato is only to be distributed to certified pharmacies, healthcare providers and specialty distributors in the Risk Evaluation and Mitigation Strategy (REMS) program due to the risk of serious adverse outcomes. This requires all pharmacies to be REMS-certified and only dispense Spravato to health care settings certified in this program as well.

 

Providers are no longer permitted to use “pharmacy bill” methodology for Spravato (HCPCS code S0013 and J3490). Instead, TRICARE only allows providers to buy-and-bill for the drug when rendering care, by utilizing G2082-83 code.

 

Humana Military is actively working with the Defense Health Agency (DHA) to learn more about the details of this change, and we will continue to share information as it becomes available.  

 

Learn more about the REMS buy-and-bill application.

Autism Care Demonstration (ACD) update

February 14, 2024

Effective January 24, 2024, all Applied Behavior Analysis (ABA) outcome measures be completed no earlier than 90 days prior to their respective due date. Please be aware of all respective outcome measure due dates to prevent a delay in authorization of services. For more information, see TRICARE Operations Manual (TOM) Ch. 18, Sec. 4, Para. 8.6.4.7.

Cystic Fibrosis (CF) coverage extended under the Laboratory Developed Tests (LDT) demonstration

February 9, 2024

TRICARE recently extended coverage for preconception and prenatal Cystic Fibrosis (CF) carrier screening, as well as the follow-on prenatal CF diagnostic genetic testing, such as amniocentesis, chorionic villus sampling, or chordocentesis, when provided in accordance with the most current American College of Obstetricians and Gynecologists (ACOG) guidelines.

 

Additionally, this screening is exempt from the preauthorization requirements of this demonstration.

 

It’s important to note, that this change also updated the naming convention of these types of tests from “Non-FDA approved LDTs” to “FDA Non-Approved LDTs.”

 

For more information, please see TRICARE Operations Manual (TOM) Ch. 18, Sec. 3, Para 2.2, Change 133.

Billing update to End Stage Renal Disease (ESRD) facilities

January 26, 2024

Billing update to End Stage Renal Disease (ESRD) facilities

TRICARE no longer considers ESRD facilities (freestanding kidney dialysis centers) as Corporate Services Providers (CSP). These freestanding ESRD facilities are now recognized as authorized institutions for reimbursement and certification requirements and must meet the following criteria for reimbursement as listed in TRICARE Policy Manual Chapter 11, Section 2.10:

  • Be classified as a freestanding ESRD facility by Medicare and be Medicare-certified
  • Be a TRICARE participating provider, and
  • Agree to accept the TRICARE payment as full payment for the care, services or supplies

 

Freestanding ESRD providers that meet the above requirements will be authorized as TRICARE institutional providers. Providers who do not meet the criteria will no longer receive TRICARE reimbursement as a CSP for dates of services on or after January 12, 2023.

 

This change aligns TRICARE with Medicare for reimbursement which includes a limitation of three dialysis sessions per week unless medical justification is provided and approved. Freestanding ESRD facilities should seek reimbursement for the facility/institutional component of dialysis sessions on a UB-04 claim form.

 

See TRICARE Reimbursement Manual (TRM), Ch. 18, Sec. 1 for more information on this change and its requirements.

 

Find out more about covered dialysis services in the TPM, Ch. 7, Sec. 4.2.

 

Find out more: ESRD Prospective Payment System (PPS) consolidated billing

New Technology Add-On Payment (NTAP) update

January 26, 2024

TRICARE has established criteria for pediatric NTAPs, as well as an approval process for a new technology to be considered for a TRICARE-designated NTAP. 

 

Pediatric-Specific NTAPs 

Pediatric NTAP inpatient hospital claims may be applied when reimbursement is equal to the lesser of 100% of:

  • the average cost of the technology, or
  • 100 % of the total covered costs that exceeds the Medicare Severity-DRG payment.

Pediatric-specific NTAPs apply to hospital discharges on or after July 1, 2022.

For more information, see TRICARE Reimbursement Manual (TRM), Ch. 6, Sec. 11, Para 4.3.

 

TRICARE-Designated NTAPs

Instances of TRICARE-covered services and supplies without a Medicare-established NTAP adjustment for Diagnosis Related Groups (DRG), may require DHA to designate a TRICARE NTAP adjustment. Technology manufacturers may request to be considered for a new TRICARE-designated NTAP by submitting this application.

 

The deadline for receipt of application is July 8 of the preceding fiscal year for the TRICARE NTAP to be considered.

 

For more information, see TRM, Ch. 6, Sec. 11, Para 4.5.

Stay up to date on TRICARE Select

January 5, 2024

Did you know TRICARE beneficiaries may be enrolled in TRICARE Select?  TRICARE Select is a self-managed, Preferred Provider Organization (PPO) plan available to eligible TRICARE beneficiaries who are non-active duty, not enrolled in TRICARE Prime.

 

How it works:

  • A provider must be TRICARE-authorized (any individual, institution/organization or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE)
  • Referrals are not required for most primary and specialty appointments
  • Prior authorization may be required from Humana Military for some services

 

TRICARE Select beneficiaries do not have Primary Care Managers (PCM) and may self-refer to any TRICARE-authorized provider. However, certain services (e.g., inpatient admissions for substance abuse disorders and behavioral health, adjunctive dental care, home health services) require prior authorization from Humana Military.

 

TRICARE Select is a great choice for your patients who:

  • live in an area where they can’t use TRICARE Prime
  • have Other Health Insurance (OHI)
  • are seeing a provider who isn’t in the TRICARE network and don’t want to switch

 

Eligible beneficiaries pay an annual outpatient deductible, cost-shares (or percentage) for covered services and Group A retirees must pay enrollment fees.

 

Find out more about TRICARE Select and encourage beneficiaries to enroll today!

Reimbursement changes for Home Health Agencies (HHA)

January 5, 2024 update

The Notice of Admission (NOA) was not adopted by the Defense Health Agency (DHA) so they are no longer required.

 

TRICARE Reimbursement Manual (TRM) Ch 12, Sec 9

Home Health Agency (HHA) reimbursement FAQs

 

February 6, 2023 update

 

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

 

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.

 

June 15, 2022 update

 

Update Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).

 

March 4, 2022 update

 

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

 

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

 

Retroactive to January 1, 2021, TRICARE has implemented the following changes.

 

National Operating Standard Cost as a Share of Total Costs (NOSCASTC)

 

The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.  

 

Split percentage payments and Requests for Anticipated Payment (RAP)

 

HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.  

 

Low Utilization Payment Adjustment (LUPA)

 

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.

 

Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.

eSHARE makes monthly provider roster submissions easier

January 5, 2024

Simplify the way you update provider data! The eSHARE electronic platform saves you time and reduces email. Using the provided template, monthly roster submissions are simpler than ever.

eShare helps providers and practices:

 

  • Control how your data appears in Humana Military’s system
  • Benefit from secure, simple and fast submissions
  • Have access 24/7 access
  • Submit your update when it is convenient for you
  • Receive instant confirmation of your acceptance
  • Receive instant alerts and instructions if additional information is needed

 

Roster changes are processed in less than 30 days.

 

Contact your Humana Military TRICARE Community Liaison (TCL) to sign up and to learn more!

Automatic Blood Pressure Monitors (BPM) coverage update

December 22, 2023

TRICARE has added coverage for automatic Blood Pressure Monitors (BPM), under TRICARE’s Durable Medical Equipment (DME) policy (TRICARE Policy Manual (TPM), Chap.8, Sect. 2.1), for patients receiving covered Remote Physiologic Monitoring (RPM) services for medically necessary blood pressure monitoring.

 

Exclusions to this coverage include:

 

  • Automatic blood pressure monitors that do not meet the TRICARE Program’s definition or coverage requirements for DME
  • Automatic BPMs for patients not receiving covered RPM services for blood pressure monitoring
  • Manual blood pressure monitors

 

Reference TPM Chap. 8, Sect. 2.1 for more information about this change and RPM services.

Automatic Blood Pressure Monitors (BPM) coverage update

December 22, 2023

TRICARE has added coverage for automatic Blood Pressure Monitors (BPM), under TRICARE’s Durable Medical Equipment (DME) policy (TRICARE Policy Manual (TPM), Chap.8, Sect. 2.1), for patients receiving covered Remote Physiologic Monitoring (RPM) services for medically necessary blood pressure monitoring.

 

Exclusions to this coverage include:

 

  • Automatic blood pressure monitors that do not meet the TRICARE Program’s definition or coverage requirements for DME
  • Automatic BPMs for patients not receiving covered RPM services for blood pressure monitoring
  • Manual blood pressure monitors

 

Reference TPM Chap. 8, Sect. 2.1 for more information about this change and RPM services.

Update to ultrasound surgery coverage details

December 20, 2023

Effective December 20, 2023, unilateral thalamotomy using Magnetic Resonance Image Guided Focused Ultrasound Surgery (MRgFUS) (CPT code 0398T) may be covered for the treatment of medication refractory essential tremor when:

  • Provided with FDA-approved devices and
  • In accordance with the American Society for Stereotactic and Functional Neurosurgery coverage criteria

 

For more information, see TRICARE Policy Manual (TPM) Chap.4, Sect. 20.1, Para. 2.14. 

Referrals and authorizations are going digital!

December 18, 2023

Humana Military is preparing to move all referrals and authorizations to electronic submissions, eliminating hard copy fax receipts. Instead, you can submit multiple documents for new and existing referrals/authorizations through provider self-service. If you have not yet done so, please adjust your referral/authorization processes now to prepare for this upcoming change.

 

If you are not currently using electronic submissions, are unable to access provider self-service or have barriers when attempting to use electronic submissions for your referrals or authorizations, please fill out this survey let us know how we can help you.

 

If you need a self-service account to begin submitting online you can create one today! For those providers who are already submitting referrals and authorizations through provider self-service- thank you!

 

See referrals and authorizations or referral/authorization demonstration or FAQs.

Changes to Freestanding Ambulatory Surgery Centers (ASC) reimbursement effective Oct. 1

December 18, 2023

Effective for service dates on or after October 1, 2023, TRICARE policy requires claims for care rendered at freestanding Ambulatory Surgery Centers (ASC) to process using the Medicare ASC Payment System for reimbursement. See the TRICARE Reimbursement Manual (TRM) Ch. 9, Sec. 2 Ambulatory Surgical Center (ASC) Reimbursement for service on or after October 1, 2023, for additional details. 

 

Freestanding ASCs that specifically service pediatric populations, and do not have a Medicare participation agreement, must be accredited by the Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC) and enter into a participation agreement with TRICARE.

 

Please see the following general guidance on claims reimbursement:

  • Freestanding ASCs that do not meet all of the above Medicare eligibility requirements are no longer eligible for reimbursement for services rendered on or after October 1, 2023.
  • For freestanding ASCs that meet the Medicare eligibility requirements, Humana Military will hold claims for their services rendered on or after October 1, 2023, until further guidance is received.  
  • For services rendered before October 1, 2023, claims will be processed using the rates found on Ambulatory Surgical Center (ASC) Payment page

 

For more information about this TRICARE policy change, visit the TRM, Ch. 9, Sec. 2

 

For more information on participating with Medicare, providers should contact the Centers for Medicare & Medicaid Services (CMS)

 

Please check back regularly as this article will be updated with the latest information.

Change to accessing basic referral information

December 18, 2023

As of December 18, 2023, Humana Military is no longer able to provide basic referral status information through the call center. To obtain this information, you must log in to your provider self-service account, or call the automated and interactive self-service phone line at (800) 444-5445.

 

Any referral issues or questions not related to basic referral details will be performed via the call center as normal. Basic referral details includes details available in self-service like effective dates, number of visits, referral status, expiration dates and type of service.

 

For more information on provider self-service account registration and accessing referral details, please visit our on-demand webinar library and view the tip sheet on TRICARE referrals and prior authorizations.

Coverage update to Mobile Medical Applications (MMA)

December 1, 2023

TRICARE recently clarified coverage criteria for Mobile Medical Applications (MMA) and related sensors based on existing TRICARE policy and regulations.

 

Per TRICARE policy, there are currently no MMAs that meet TRICARE coverage criteria. Once an MMA meets all criteria, the relative paragraph will be updated in the TRICARE Policy Manual (TPM).

 

TPM Ch 1, Sec 1.2, Para. 1.1.68 states “Mobile Medical Applications (MMAs) and other digital therapeutics are excluded unless listed as covered by the TRICARE Program in TPM Ch. 8, Sec.2.1, Para. 3.12.5.”

Rare diseases and fetal surgery coverage update

October 20, 2023

On November 13, 2023, TRICARE is adding coverage of fetoscopic and other minimally invasive surgery for the treatment of a rare disease, myelomeningocele (MMC). Cost-sharing may be considered when the gestational age of the fetus is 19.0 to 25.9 weeks and MMC is present with an upper boundary located between T1 through S1 with evidence of hindbrain herniation.

 

For more information, see TRICARE Policy Manual (TPM) Ch. 1, Sec 3.1, Para 2.31 and TPM Ch. 4, Sec.18.5.

Change to cancer and children’s hospital Outpatient Prospective Payment System (OPPS) reimbursement methodology

October 19, 2023

Effective for dates of service on or after October 1, 2023, cancer and children’s hospitals TRICARE maximum allowed reimbursement methodology for outpatient claims will begin to process using the Outpatient Prospective Payment System (OPPS) (TRICARE Reimbursement Manual (TRM), Ch. 13, Sec. 1, Para. 3.4.1.1.5), and blended rates for radiology will end (TRM, Ch. 1, Sec. 24, Para. 2.9.7).

 

For more information on the OPPS billing and reimbursement policy see Ch. 13. To learn more about the hold-harmless provision, see TRM Ch. 13, Sec. 3, Para. 3.1.5.8.

 

For more information about these changes to TRICARE reimbursement methodology, visit our FAQs.

Avoid improper billing practices

September 1, 2023

Providers that make coding decisions that result in overbilling are committing fraud. Abuse can occur when a provider's billing practices, which may be direct or indirect, causes a financial loss even if there is not intent. One example of these practices that lead to overbilling is known as unbundling.

 

Unbundling occurs when multiple procedures/services are improperly billed separately, even though the group of services is covered by a single comprehensive code.  It can result in a higher reimbursement than the provider is entitled to receive.

 

Appending unwarranted modifiers to override the claims auditing software and allow additional payment for services that would normally be bundled is also considered fraudulent.

 

Unbundling fraud in the TRICARE program results in unlawful reimbursement at the taxpayer’s expense.  TRICARE providers are required to abide by all TRICARE program and Humana Military rules and guidelines for coding that are applicable when billing for services provided to beneficiaries. Manipulating CPT codes as a means of increasing reimbursement is considered improper billing practices and a misrepresentation of services billed.

 

Examples of fraud:       

  • Billing for costs of nonchargeable services, supplies or equipment disguised as covered items
  • Misrepresentations of description of services rendered

Update to Laboratory Developed Test (LDT) demonstration

August 18, 2023

The Laboratory Developed Test (LDT) demonstration has been extended through July 18, 2028, and the following LDTs have been added: 

  • Biotheranostics Breast Cancer Index
  • DermTech Pigmented Lesion Assay (PLSA)
  • FoundationOne Heme
  • MDxHealth Confirm MDx 
  • MDxHealth Select MDx

 

Cystic Fibrosis (CF) carrier screening is now covered under the TRICARE basic benefit as a preconception and prenatal carrier screening test, as well as under the LDT demonstration for the following indications:

  • confirmation of diagnosis in individuals showing clinical symptoms of CF or having a high sweat chloride level
  • identification of newborns who are affected with CF
  • identification of individuals with the p.Gly551Asp variant who will respond to treatment with ivacaftor
  • male infertility testing and treatment

 

Learn more about LDTs

 

TRICARE Manuals - Chap 18 Sect 3 (Change 125, Jul 28, 2023) (health.mil)  

Referrals and authorizations are going digital!

August 22, 2023

Humana Military is preparing to move all referrals and authorizations to electronic submissions by the end of 2023 and will no longer accept hard copy faxes. Through provider self-service, you can submit multiple documents for new and existing referrals and authorizations.  

 

If you are not currently using electronic submissions, are unable to access provider self-service or have barriers when attempting to use electronic submissions for your referrals or authorizations, please fill out this survey to let us know how we can help you.

 

If you need a self-service account to begin submitting online you can create one today! For those providers who are already submitting referrals and authorizations through provider self-service- thank you!

 

See referrals and authorizations or referral/authorization demonstration or FAQs

New basic eligibility verification policy

June 9, 2023

Effective July 24, 2023, providers will no longer be able to obtain basic eligibility details from the call center and must use either self-service or call our automated system at (800) 444-5445.

 

Basic eligibility details include benefit and coverage types, sponsor information, effective dates, copay and cost-share info, catastrophic cap, deductibles and Other Health Insurance (OHI) information can be found in self-service!

 

Any eligibility issues or questions not related to basic eligibility verification will be performed via the call center as normal.

 

For more information, check out the Provider Eligibility FAQs.

Silicon Valley Bank (SVB)/ Signature Bank closures

March 17, 2023

The Federal Deposit Insurance Corporation (FDIC) announced that it has assumed control of Silicon Valley Bank (3/10/23) and Signature Bank (3/12/23) to meet the needs of its depositors and ensure there are no risks to the account holders. As such, the FDIC has established bridge banks and moved all deposits to these respective banks to ensure access by the account owners with little interruption of services. This process should be seamless to the account holders; more information is available on the FDIC website.


Earlier this week, claims payments were suspended for providers with these banking arrangements until the initial assessment of this issue was compete. The assessment is now complete and at this point, we do not see an inherent issue with provider payments based on the information available from the FDIC. As such, payments currently held will be released and issued in the normal time frames.


If providers wish to change their current payment arrangements to a different bank or select paper checks, they can visit the WPS/Change Healthcare portal for Electronic Funds Transfer (EFT)/ Electronic Remittance Advice (ERA) or learn more by viewing these FAQs on how to change a healthcare payer’s enrollment services.


We apologize for any inconvenience this may cause, but we wanted to ensure receipt of payments in a secure manner for the services provided. Please reach out to your local TRICARE Community Liaison (TCL) should you need further assistance.

Access to Spravato®

March 16, 2023

The nasal spray, Spravato® (esketamine), is covered when deemed medically necessary to treat beneficiaries with treatment-resistant depression and other US Food and Drug Administration (FDA)-approved indications, which are available in the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program. This benefit is covered under the medical benefit, not pharmacy, and prior authorization is required.

While Walgreens is not a network provider at this time, prescriptions for Spravato (esketamine) can be filled through Walgreens Specialty Pharmacy.

Reimbursement changes for Home Health Agencies (HHA)

February 6, 2023 update

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.
 

TRICARE Reimbursement Manual (TRM) Ch 12, Sec 9

Home Health Agency (HHA) reimbursement FAQs
 

June 15, 2022
 

Update Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).


March 4, 2022 - Update
 

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

Retroactive to January 1, 2021, TRICARE has implemented the following changes.


National Operating Standard Cost as a Share of Total Costs (NOSCASTC)
 

The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.


Split percentage payments and Requests for Anticipated Payment (RAP)
 

HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.


Low Utilization Payment Adjustment (LUPA)
 

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.

Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.

Update to TRICARE's Childbirth and Breastfeeding Support Demonstration (CBSD)

August 24, 2023

TRICARE’s Childbirth and Breastfeeding Support Demonstration allows Certified Labor Doulas (CLD), lactation consultants or lactation counselors to provide care to eligible beneficiaries.

 

Effective July 25, the following telemedicine services for the CBSD are no longer included:

  • Audio-only breastfeeding counseling
  • Antepartum and postpartum care visits

 

Please note: All childbirth support services provided by a Certified Labor Doula (CLD) must be in-person.

 

As a reminder, providers must use a two-way visual component to provide breastfeeding support services via telemedicine.

 

To verify you are able to continue to provide these services, please review Telemedicine for providers.

 

For more information on the CBSD, visit TRICARE Operations Manual and CBSD provider resources.

Get the latest on the COVID-19 Public Health Emergency ending

May 16, 2023

The COVID-19 Public Health Emergency (PHE) expired on May 11, 2023 along with TRICARE’s temporary coverage and payment for certain services. As a result, key impacts due to the expiration of the PHE include (but are not limited to):

Relaxation of state professional licensing requirements

The temporary relaxation of state professional licensing requirements has expired.

 

TRICARE coverage of acute care facilities and temporary expansion of hospital sites, including Medicare’s Hospitals Without Walls (HWW) initiative

Coverage of temporary hospitals, freestanding Ambulatory Surgical Centers (ASC), and other entities enrolled with Medicare as hospitals expires upon the expiration of Medicare’s HWW initiative.

Claims for dates of services through the PHE expiration date will continue to process under the temporary classification.

Organizations previously considered a TRICARE-authorized, freestanding ASC may return to that classification, provided all federal and state licensure/certification requirements are current.

If your organization wishes to participate in TRICARE as a hospital and has been certified as such by Centers for Medicare & Medicaid Services (CMS) or The Joint Commission (TJC), please visit HumanaMilitary.com/certify to submit a hospital application.

 

Certain Critical Access Hospital (CAH) participation requirements

The requirements that CAHs provide 24-hour emergency care services and no more than 25 beds for acute, hospital-level inpatient care, or swing beds for Skilled Nursing Facility-Level care, and maintain a length-of-stay of no more than 96 hours, determined annually, expire.

You can visit TRICARE Coverage and Payment for Certain Services in Response to the Coronavirus Disease 2019 (COVID-19) Pandemic for complete details on each amendment to TRICARE policy.

 

Skilled Nursing Facilities (SNF) three-day prior hospital stay requirement waiver

The waiver for a qualifying hospital stay of three consecutive days or more, not including hospital discharge day, prior to SNF admission, expired on April 10, 2023 with the President’s termination of the national emergency.

You can visit Temporary Reimbursement Changes In Response To The Coronavirus Disease 2019 (COVID-19) Pandemic for complete details.

Increase to number of milk bags covered every 30 days

May 10, 2023

Starting on May 3, 2023, TRICARE now allows a refill of 100 breast milk supply bags every 30 days following a birth event. This is an increase from 90 bags.

 

Learn more

Clarification on Partial Hospitalization Programs (PHP) claims and codes

June 21, 2023

When billing Partial Hospitalization Program (PHP) services, revenue codes 0913 or 0912 should be filed with the correct Healthcare Common Procedure Coding System (HCPC) code to allow the system to calculate the appropriate allowed amounts to ensure proper payment.

 

Note: Revenue codes must be billed separately for each date of service.

 

Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) claims are to be submitted per policy as listed below:

 

Non-Outpatient Prospective Payment System (OPPS) payable providers

  • Revenue code 0912 can be billed with HCPCS H0035 or by itself for half-day service
  • Revenue code 0913 can be billed with HCPCS H0037 or by itself for full-day service
  • Revenue code 0905 or 0906 can be billed with H0015 or S9480

 

OPPS payable providers

  • Revenue codes 0914 and 0915 are payable only to OPPS providers. Please reference figure 13.2.1 for the listing of OPPS payable HCPCS codes referenced in the TRICARE Reimbursement Manual provided below
  • Revenue code 0905 or 0906 can be billed with H0015 or S9480
  • All claims must be billed with condition code 41 on CMS 1450 UB-04 Claim Form

 

For guidance, please see TRICARE Reimbursement Manual, Chapter 13, Section 2.

 

A note on claims corrections

Claims corrections will occur on all PHP and IOP providers whose claims were incorrectly paid due to this issue. Providers will receive a details spreadsheet listing all claims that have been incorrectly billed.

 

Providers will have the option to correct either the HCPCS code or revenue code. To correct the spreadsheet, add the correct code to the column which best represents the service provided. After reviewing all claims on the spreadsheet and updating the column appropriately. This will serve as documentation to make corrections to the claims. Send the file to the email or mailing address below.

 

Recoupment action will be initiated 60 days after the date of this notice for all claims that were overpaid if no action is received from the provider. The provider can submit a corrected claim.

 

Email

TRICAREEastProviderInquiry@humana.com

 

Mail

TRICARE East Region claims

Attn: Corrected claims

PO Box 8904

Madison, WI 53708-8904

 

Fax

(608) 327-8523

Submit your certification applications digitally

September 1, 2023

*Humana Military has moved all certification applications to a digital format, and starting October 1, 2023, will no longer accept paper or PDF applications. Providers who submit paper versions on or after October 1 will receive a letter back that they need to complete their application electronically, potentially delaying the certification process.

 

Please dispose of any paper applications or PDFs you have on hand, and instead access our most current, digital versions at HumanaMilitary.com/certify.

 

What are the benefits of digital certification applications?

  • Faster processing time
  • Instant electronic confirmation of receipt
  • Check applicaiton status online
  • Improved submission accuracy
  • Real-time feedback
  • Captures all necessary attachments
  • Prevents submission of incomplete applications
  • Less touchpoints—no need to call or email to confirm receipt or follow-up

 

Thank you for your cooperation as continue to work to enhance the certification application process.

 

*After October 1, the only remaining print certification applications will be Telehealth Only applications.  

Abortion billing tips

November 30, 2022

To receive correct reimbursement, please ensure all required information is included, per TRICARE Policy Manual (TPM) Chapter 4 Section 18.3.


Claims must be submitted with the following:
 

G7 modifier, which is defined as the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening

One of the condition codes listed below: 

AA - Abortion performed due to rape;

AB - Abortion performed due to incest;

AD - Abortion performed due to life endangering physical condition

For more information, visit TRICARE.mil.