TRICARE Overseas Program Provider Manual

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TRICARE overseas Program Provider Manual If the patient does have another health insurance paying before TRICARE select ‘Yes.’ When you select ‘Yes’ the screen will update to display 3 additional fields to provide the payment information from the OHI: ■ other Health Insurance Allowed – Enter the amount the OHI indicated as its ‘Allowed’ amount for the entire claim. Enter this amount in $USD (United States Dollars). ■ other Health Insurance Paid – Enter the amount the OHI paid for the entire claim. Enter this amount in $USD (United States Dollars). ■ other Health Insurance Payment Reason – The OHI will typically provide a code or comment explaining how they processed the claim. Click the ‘Look Up’ and from the pop-up box, select the reason that matches the OHI explanation. — Either Deductible, Copay/Cost Share, Non-Covered Service or Other. — Note: This is a required field when there is OHI, so if there is no payment reason from the OHI or if there isn’t one that matches these choices, select ‘Other.’ Be aware that claims transactions involving OHI must be conducted in $USD (United States Dollars). The currency type for the claim will default to $USD and cannot be changed. If you previously entered a patient payment amount in a currency other than $USD, please return to that field and enter the correct amount for $USD currency. You can select a currency type for the claims transaction from a drop down menu. However, if the claim transaction does include OHI, this option will not be available as the claim transaction with OHI must be in $USD. online Claim Submission: Claim Line Item Form To use the ‘Lookup’ feature: • Click on ‘Code Lookup’ • The CPT/HCPCS Lookup pop-up box will appear • Type the description of the procedure in the box • Click the ‘Search’ button A list of descriptions containing your search word will appear. The code corresponding to each description appears in the column to the left of the description. Find the diagnosis description for your claim and then click the code to the left to enter it into the CPT/ HCPCS field of the online claim form. 46
TRICARE overseas Program Provider Manual The ‘Claim Line Item Form’ section is for entering the details about the medical services and/or supplies provided during the health care encounter. The ‘Claim Line Item Form’ section is not a summary section: you can enter multiple procedures per claim. Each procedure will have its own claim line. Note: Required fields are indicated with an asterisk. Begin by entering the dates of service for the procedure. Dates of service can be typed directly into the ‘From’ and ‘To’ fields or you can use the calendar icon to select the dates of service. Note: The required format for the ‘Dates of Service’ fields is Month, Day and Year. Enter the Current Procedural Terminology (CPT) code or the Health Care Procedure Coding System (HCPCS) code that represents the medical procedure or service that was performed. If you know the code representing the procedure or supply, you can type it directly into this field. The ‘Modifier’ field is used to enter 2 character codes that represent additional descriptors or clarifiers to the procedure performed. The modifier is not a required field and can be left blank. The ‘National Drug Code’ field is for listing the code the United States Food and Drug Administration assigns to any marketed prescription drug or insulin. This field is not required and should be left blank unless the medical procedure code entered in the CPT/HCPCS field represents a prescription drug or insulin. The ‘Anesthesia’ field should be checked ‘Yes’ only if the code entered in the CPT/HCPCS field represents anesthesia. If you selected ‘Yes’ here, the ‘Units’ field should be entered with the number of minutes anesthesia was administered. The ‘Units’ field is for entering the number of times the procedure in the CPT/HCPCS field was performed during the dates of service OR it should represent the number of units of the supply provided. Note: If the procedure or supply is a prescription or injection and the National Drug Code was also provided, enter the National Drug Code quantity in this field and not the HCPCS quantity. If you selected ‘Yes’ in the Anesthesia field, the number of units should be the number of minutes billed for anesthesia. The ‘Charges’ field is used to enter the amount you are billing for the procedure or service. Type the amount directly into these fields. Note: The amount entered in this field must be in the currency type selected in the ‘Claim Information’ section of the form. If the ‘Currency Type’ field displays $USD (United States dollars), the amount entered here must also be in $USD. The ‘Place of Service’ field is for entering the 2-digit code that describes the type of facility where the procedure was performed. If you know the correct code, it can be typed directly into this field. If you do not know the code, click the ‘Lookup’ button. A pop-up box with a list of descriptions will appear. The ‘Place of Service’ code corresponding to each description displays in a column to the left of the description. Select the code for the description that matched the location description to enter it into the ‘Online Claim Form.’ The ‘Service Location Zip Code’ field is an optional field, but if applicable enter the Zip Code of the location where the services were rendered in this field. This field only accepts Zip Codes in a 5-digit, allnumeric format. If your service location Zip Code does not meet the required format, leave this field blank. The ‘Provider’ field is a drop down menu of names of individuals on file for the ‘Provider Location’ you selected at the start of the ‘Online Claim’ submission process. Choose the name of the individual that performed the procedure or service given in the CPT/HCPCS field. If the name of the individual is not listed here, you can add them to the provider list for the location through the ‘Administration’ console OR if you cannot add them, you will not be able to include the procedures or services that person performed in your online claim submission. You have the option to provide comments or additional information to the line item you are currently entering. Click the ‘Insert Comment’ link to open a box that will allow you to enter up to 80 characters of text to accompany this procedure or service item. Once you have entered all required information for the procedure or service in the ‘Claim Line Item Form’ fields, click the ‘Add Line Item’ button to include the item in your claim. When you click the ‘Add Line Item’ button, the information for the procedure or service item in the ‘Line Item Form’ will move to the ‘Line Item List’ section, displaying all details you entered for the item. The ‘Claim Line Item Form’ fields will reset to blank so that additional procedures or services can be entered on your claim. online Claim Submission: Line Item List The ‘Line Item List’ section will display all procedure or service items you have added to the claim, along with all details you entered for each item. If you need to correct or modify a line item, select the ‘Edit’ button for that item. If the line item should not be submitted with the claim, select the ‘Delete’ button for that item to completely remove it from the claim before submission. At the end of the ‘Line Item List’ section, the Total Charges are given for the claim. The total charges will be the sum of the charges in the currency type you selected for all line items you have added to the claim. Once you have completed entering line items to your claim, click the ‘Next’ button SECTIoN 5 Provider Claims Information 47
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