Pediatric Coding Alert

Bill Tricare after private payers, but before Medicaid.

Whether your office is right near a military base or you’re miles away from the closest one, chances are strong that you see Tricare patients regularly. Although this government payer’s rules might seem tricky to follow, help is on the way. Consider the following five Tricare facts that can help you cut denials.

Fact 1. Tricare requires timely filing. Your practice most likely files claims on the date of service, but practices often find un-filed claims during internal audits or record reviews, and you may want to send in claims later than usual. In the case of Tricare, you only have a year from the date of service (or a year from the discharge date for inpatients)—after that, the claim will be denied. For more on this, see www.tricare.mil/Resources/Claims/MedicalClaims/FilingTips.aspx.

Fact 2. Speech therapy is covered—if you meet the criteria. Tricare does include coverage for speech therapy to treat speech, language and voice dysfunctions that occur due to diseases, injuries, birth defects, hearing loss and pervasive developmental disorders, the payer says on its website. However, if you’ve been struggling to collect for these services from Tricare, you could be treating a patient that doesn’t meet the criteria.

Speech therapy is not covered for disorders resulting from educational deficits, myofunctional tongue thrust therapy, videofluoroscopy evaluations, maintenance therapy that doesn’t require a skilled level or special education services. If your patient falls into this category, chances are that the services will be only available to Tricare patients on a cash-pay basis, and you should request that the parent sign an advance beneficiary notice (ABN) in these instances. For more, read www.tricare.mil/CoveredServices/IsItCovered/SpeechTherapy.aspx?sc_database=web.

Fact 3. Well visits don’t trigger copays—but other services with them do. As most practices are aware, the Patient Protection and Affordable Care Act (PPACA) that became law in 2010 requires you to provide preventive care visits consistent with Bright Futures Guidelines for children at no cost to the patient or family, including well child exams, vision and hearing screening, immunizations, and obesity counseling, among other services.

These visits are not subject to a copay, coinsurance or deductible, so patients who schedule them come to your practice expecting to leave without paying any money out of their pockets.Tricare supports the waived copay, but keep in mind that if you perform other services during those “free” visits, then the other services “are subject to appropriate cost-sharing and deductibles,” Tricare advises on its website. For more information, visit www.uhcmilitarywest.com/uhcmilitarywest/Files/pdfs/Provider Claims Tip Sheet.pdf.

4. Tricare is always the secondary payer—with a few exceptions. If a particular patient has Tricare as well as insurance through another source, you should almost always consider the other insurance primary. “By law, Tricare pays after all other health insurance except for Medicaid, Tricare supplements, state victims of crime compensation programs or other federal government programs (i.e., Indian Health Services),” Tricare says on its website.

Keep in mind that the exception above applies to Medicaid, but not Medicare. Therefore, if you see a disabled pediatric patient who is on Medicare via her disability, but also has Tricare, you should submit the claim to Medicare first, and then the balance bill can go to Tricare. If, however, the patient has both Medicaid and Tricare, bill Tricare first, and then file with Medicaid. 

For more on this issue, see www.tricare.mil/Plans/OHI.aspx.

5. Tricare wants descriptions of unlisted claims. Much like your other payers, Tricare isn’t very keen on paying claims with unlisted or unspecified codes. If you submit a claim with an unlisted service code on it, you should also submit “supporting documentation describing the services rendered must be included or the claim will be returned or denied for this information,” says HealthNet Federal Services, the claims processing partner for Tricare’s Northern Region.

To read further in depth about this topic, visit www.hnfs.com/content/dam/hnfs/tn/prov/resources/pdf/2015_QRC_Claims_Billing.pdf.