Our office has a lot of Tricare patients. (West Region) As of 01/01/2018 UnitedHealthCare no longer processes claims for Tricare. Healthnet took Tricare over. I have searched the internet for the new claims address with no luck. I have tried to call them since the first of the year and get nothing but busy signals.
Can someone please let me know what the new claims address is for the West Region? And payer ID?
I work for Internal Medicine and having trouble with CGMS medical necessity but only for certain insurances mostly Tricare and some BCBS policies.
Medicare, Medicare Advantage paid as well as a couple of commercial like Mailhandlers and United. Most of our patient have Type II DM, but the reason we are utilizing the continuous glucose monitor option because we have label A1C levels and the provider wants to see a clearer picture if diet and/or medication management needs to be adjusted. I simply used the Type II DM code with the hyper or hypoglycemia manifestation code and I got reimbursed. All of the sudden Tricare and some BCBS policies denied for medical necessity. I talked to Tricare and BCBS but no help from them of course. On the Tricare website I found the medical necessity (Tricare Policy Manual 6010.60-M, April 1, 2015 Chapter 8, Section 5.3) which lists that Hypoglecemic unawareness (E16.2) is a covered DX. I rebilled all my denied claims to Tricare and I just posted the denial for the same reason, non-covered DX. I understand that Tricare only wants to pay for Type I DM?
Is this one of those cases where even though everyone "should" follow Medicare guidelines, they just refuse, or slow to implement this procedure? Does anyone got paid from North Region Tricare for CPT 95250 and 95251 (CGMS) for patient who did not have Type I DM?
Any help is appreciated.
Heni Mercer, CPC
A few months ago, our practice began receiving multiple Tricare refund requests due to "the recommended drug/vaccine dosage for the National Drug Code (NDC) units from the manufacturer has been exceeded."
The claims listed were from 2013-2016 and totaled thousands of dollars. I was taught to report the NDC#’s as 5-4-2 format and each vaccine = 1 unit. Our software doesn’t support this so I have to manually enter these claims directly into MyTricare.com. I’ve contacted Tricare by phone and letter, but they only direct me to their online guidelines which appear to validate what myself, and the person before me, billed. When I called for help, I was told to refer to the FDA’s website because Tricare doesn’t have a list of vaccines and how they should be reported.
We have no choice but to refund this money, but I want to know what I’m doing wrong so this doesn’t happen again in another 3 years. Tricare is the only insurance that claims we are overbilling.
Thank you in advance to anyone who can help explain this to me.