TRICARE Overseas Program Provider Manual

TRICARE overseas Program
Provider Manual
Required Criteria for Ensuring
Payment of Claims
Providers can help to ensure that claims are processed (and
payments made) in a timely manner, by making sure that the
following minimum required fields are completed on their Claim
Form, before it is submitted:
CMS 1500:
1. TRICARE Ticked
2. Patient Name
3. Patient Address
4. Sponsor Name
5. Sponsor’s Social Security Number or DOD Benefits Number
6. Other Health Insurance (OHI) Details (if applicable)
7. Patient Signature x2 and the date
8. Diagnosis (if this cannot be written on the invoice)
9. Authorization Number
10. Federal Tax ID (Provider ID or TEPRV)
11. Accept Assignment? YES
12. Amount Paid by OHI or Beneficiary (if applicable)
13. Provider Signature
14. Provider Name and Billing Address
UB-04:
1. Provider Name and Billing Address
2. Federal Tax ID (Provider ID or TEPRV)
3. Patient Name
4. Patient Address
5. Other Health Insurance (OHI) Details (if applicable)
6. Assignment of Benefits – YES
7. Amount Paid by OHI or Beneficiary (if applicable)
8. Sponsor Name
9. Sponsor’s Social Security Number or DOD Benefits Number
10. Authorization Number
11. Diagnosis (if this cannot be written on the invoice)
12. Provider Signature
Providers must also ensure that the Itemized Invoice they submit
contains all of the following information:
■ Date of Service
■ Letterhead Containing the Provider’s Name, Physical Address
and Billing Address
■ Invoice Number or Patient Account Number
■ Corresponding Authorization Number (when required) prior to
Treatment (this can be found on the Authorization Form)
■ Patient Name
■ Description of Diagnosis (if the diagnosis cannot be written on
the invoice, please include this on the Claim Form)
■ Breakdown of Services Rendered, Listing Corresponding
Costs (and Taxes) and Overall Total Owed
■ Invoice Currency
Important: Claim Forms that are received without an invoice, or
invoices that are received without a Claim Form will not be
processed. The received document will be returned to the
Provider.
Note: If Providers would like to receive payment for claims in the
fastest possible time, International SOS recommends using the
Online Claim Submission option via the Provider Portal AND
registering to receive EFT payments. This helps avoid the delays
associated with overseas mailing times.
Explanation of Benefits and
Applicable Exchange Rate
Information
Remittance Advice is sent to the Provider in the form of an EOB.
EOBs are sent to the Provider by mail however this information is
also available to be viewed online via the Provider Portal. The
electronic EOB is available on the same date the payment is
issued.
The EOB includes detailed information regarding any items that
may have been denied for payment. It also includes important
exchange rate data, which was used for issuing payment.
Deductibles and co-payments that TOP Standard beneficiaries
are responsible for paying will also be included on the EOB.
According to TOP policy, the exchange rate applied will be the
exchange rate valid on the last day of the ‘episode of care’ or last
date of invoiced services. Citigroup is the standard exchange
rate used by International SOS.
If a claim is denied or not paid in full, a denial code will be
assigned to that charge. An explanation of the denial codes
is included on the last page of the EOB. A list of denial
codes and their explanations is available online at
www.tricare-overseas.com as well as in the Appendix of this
TOP Provider Manual.
You can also contact your TOP Regional Call Centre or submit a
request via the Secure Message Transmission option on the
Provider Portal.
Note: Responses to Secure Messages transmitted via the
Provider Portal will be sent to the Secure Message Inbox on the
Provider Portal. Please see Section 6: The Provider Portal for
additional information about accessing Secure Messages.
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