TRICARE Overseas Program Provider Manual

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
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