SECTION 5: Provider Claims Information - TRICARE Overseas

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TRICARE overseas ProgramProvider ManualRequired Criteria for EnsuringPayment of ClaimsProviders can help to ensure that claims are processed (andpayments made) in a timely manner, by making sure that thefollowing minimum required fields are completed on their ClaimForm, before it is submitted:CMS 1500:1. TRICARE Ticked2. Patient Name3. Patient Address4. Sponsor Name5. Sponsor’s Social Security Number or DOD Benefits Number6. Other Health Insurance (OHI) Details (if applicable)7. Patient Signature x2 and the date8. Diagnosis (if this cannot be written on the invoice)9. Authorization Number10. Federal Tax ID (Provider ID or TEPRV)11. Accept Assignment? YES12. Amount Paid by OHI or Beneficiary (if applicable)13. Provider Signature14. Provider Name and Billing AddressUB-04:1. Provider Name and Billing Address2. Federal Tax ID (Provider ID or TEPRV)3. Patient Name4. Patient Address5. Other Health Insurance (OHI) Details (if applicable)6. Assignment of Benefits – YES7. Amount Paid by OHI or Beneficiary (if applicable)8. Sponsor Name9. Sponsor’s Social Security Number or DOD Benefits Number10. Authorization Number11. Diagnosis (if this cannot be written on the invoice)12. Provider SignatureProviders must also ensure that the Itemized Invoice they submitcontains all of the following information:■ Date of Service■ Letterhead Containing the Provider’s Name, Physical Addressand Billing Address■ Invoice Number or Patient Account Number■ Corresponding Authorization Number (when required) prior toTreatment (this can be found on the Authorization Form)■ Patient Name■ Description of Diagnosis (if the diagnosis cannot be written onthe invoice, please include this on the Claim Form)■ Breakdown of Services Rendered, Listing CorrespondingCosts (and Taxes) and Overall Total Owed■ Invoice CurrencyImportant: Claim Forms that are received without an invoice, orinvoices that are received without a Claim Form will not beprocessed. The received document will be returned to theProvider.Note: If Providers would like to receive payment for claims in thefastest possible time, International SOS recommends using theOnline Claim Submission option via the Provider Portal ANDregistering to receive EFT payments. This helps avoid the delaysassociated with overseas mailing times.Explanation of Benefits andApplicable Exchange RateInformationRemittance Advice is sent to the Provider in the form of an EOB.EOBs are sent to the Provider by mail however this information isalso available to be viewed online via the Provider Portal. Theelectronic EOB is available on the same date the payment isissued.The EOB includes detailed information regarding any items thatmay have been denied for payment. It also includes importantexchange rate data, which was used for issuing payment.Deductibles and co-payments that TOP Standard beneficiariesare responsible for paying will also be included on the EOB.According to TOP policy, the exchange rate applied will be theexchange rate valid on the last day of the ‘episode of care’ or lastdate of invoiced services. Citigroup is the standard exchangerate used by International SOS.If a claim is denied or not paid in full, a denial code will beassigned to that charge. An explanation of the denial codesis included on the last page of the EOB. A list of denialcodes and their explanations is available online atwww.tricare-overseas.com as well as in the Appendix of thisTOP Provider Manual.You can also contact your TOP Regional Call Centre or submit arequest via the Secure Message Transmission option on theProvider Portal.Note: Responses to Secure Messages transmitted via theProvider Portal will be sent to the Secure Message Inbox on theProvider Portal. Please see Section 6: The Provider Portal foradditional information about accessing Secure Messages.50
TRICARE overseas ProgramProvider ManualBelow are sample EOB statements for TOP Prime and TOP Prime Remote beneficiaries:Here are the Provider’s details. Thisis to whom the payment is made.The number in this corner will be a localtoll free number which the Provider cancall if they need assistance.®This is the Claim Number, also known as theInternal Control Number (ICN).The Check Number helps Providers match the payments that have been made to the Claims they have submitted. If the Provider hasbeen paid by check, this number will correspond with the check number on the payment check. If the Provider has been paid bybank draft, this number will correspond with the number on the perforated record attached to the bank draft. If the Provider has beenpaid by Electronic Fund Transfer (EFT) up to six check numbers will appear in the payment line on the bank statement.®SECTIoN 5Provider Claims InformationThis is theCheck Number.51
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SECTION 5: Provider Claims Information - TRICARE Overseas

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