TRICARE For Life
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Important Notice Regarding Change in Timely Filing of TRICARE Claims for Participating Provider Claims.
TRICARE requires that all claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.
Effective February 1, 2010, the claims filing deadline also applies to claims submitted by participating providers. Previously the claims filing deadline was only applied to claims submitted by non-participating providers or TRICARE beneficiaries. In accordance with the TRICARE Operations Manual, Chapter 8, Section 3, there are limited circumstances in which the contractor may waive the claims filing deadline. All requests for exceptions to the claims filing deadline must be submitted in writing.
Please submit all outstanding TRICARE for Life claims prior to the one year filing limit.
For more information, please refer to the TRICARE Operations Manual at http://manuals.tricare.osd.mil/.
Prior Authorization Requirements for TRICARE for Life Beneficiaries
Prior authorization is required for some services when TRICARE for Life (TFL) is the primary payer instead of Medicare.
All services listed below must be reviewed by WPS/Tricare for Life (TFL) for medical necessity and require prior authorization when TRICARE is primary payer instead of Medicare. As secondary payer to Medicare, WPS/TFL will rely on Medicare's determination and NO authorization is required.
If you have authorization from a TRICARE Managed Care Support Contractor (Triwest, Humana or Health Net Federal Services) that cover the dates on your claim, we will honor those authorizations and NO TFL authorization is required. A ten percent payment reduction will apply to a provider's failure to obtain a required authorization.
Answering TRICARE For Life (TFL) Claims Questions
The TRICARE For Life (TFL) program is TRICARE's supplement to Medicare and is administered by Wisconsin Physicians Services (WPS). For claims information you should contact WPS' TFL Customer Service through the secured portal by registering an account on TRICARE4u.com. You can also reach them by phone at 1-866-773-0404.
The following information provides an overview of the TFL program to answer some basic questions on how the program operates as well as offering various TFL resources. TFL program highlights
How TFL Works
The provider first files claims with Medicare. Medicare pays its portion and electronically forwards the claim to WPS, the TFL claims processor. WPS sends its payment for TRICARE-covered services directly to the provider. Beneficiaries receive a Medicare Summary Notice from Medicare and a TFL explanation of benefits (EOB) from WPS indicating the amounts paid. Providers receive an EOB from WPS.
Other Health Insurance
TRICARE/Medicare beneficiaries with other health insurance (OHI), such as a Medicare supplement or employer-sponsored health plan, may also use TFL. By law, TRICARE pays claims only after an OHI plan has paid.
Typically, after Medicare processes a claim, the claim is forwarded to the beneficiary's OHI. Once the OHI processes the claim, the beneficiary or the provider will need to file a paper claim with TRICARE for any out-of-pocket expenses. TRICARE may reimburse the beneficiary for services covered by TRICARE.
TFL Referrals and Authorizations
Because Medicare is the primary payer, there is usually not a requirement for providers to obtain referrals or prior authorization from TriWest. If Medicare benefits are exhausted, or if the patient is seeking care covered by TRICARE but not Medicare, you may need an authorization from TriWest when applicable.
TRICARE has also adopted Medicare's Skilled Nursing Facility (SNF) Prospective Payment System (PPS) payment methods and rates, including Minimum Data Set (MDS) assessments, Resource Utilization Group (RUG) - III classifications, and Medicare weights and per diem rates for all SNF admissions on or after August 1, 2003. Below are a few SNF program highlights, for a on line tutorial and additional SNF information please visit the WPS TFL website at www.tricare4u.com.
How to Identify TFL Beneficiaries
Each TFL beneficiary must present a valid uniformed services ID card, as well as a Medicare card, prior to receiving services. You should copy both sides of the cards and retain the copies for your files. There is no TFL ID card. To verify TFL eligibility, simply register an account on TRICARE4u.com. That will give you access to the secure portal where you can log-in to verify patient eligibility. You can also contact Wisconsin Physicians Service (WPS) by phone 1-866-773-0404. You may call 1-800-772-1213 to confirm a patient's Medicare status.