Module 13 Claims amp; Appeals.ppt

Module 13: Claims Appeals Module Objectives After this module, you should be able to: Identify claim basics and where to submit claims Recognize who is responsible for filing the claim Identify the four appeal types Describe what can and cannot be appealed * Claim Basics Claims are filed to issue payment for services or supplies provided by civilian sources of medical care The person who submits the claim is either the provider of services or supplies, or the beneficiary Only authorized providers can submit claims for reimbursement An authorized provider is one approved under TRICARE for services or supplies provided to a beneficiary and who receives payment directly from TRICARE Any TRICARE-eligible beneficiary can submit a claim for reimbursement * Submitting Claims Claims are submitted to the claims processor responsible for the region in which the beneficiary lives or is enrolled There are two major TRICARE medical claims processors: Palmetto Government Benefits Administration (PGBA) handles claims for the North and South regions Wisconsin Physicians Service (WPS) handles claims for the West and Overseas regions, as well TRICARE for Life claims (regardless of stateside region) If a claim is sent to the wrong claims processor, the claim is either forwarded to the correct processor or returned to either the provider or beneficiary * Who is Responsible for Filing the Claim? Beneficiaries are responsible for ensuring claims are submitted and processed, no matter who submits the actual claim If the beneficiary sees a network provider, the provider is responsible for filing the claim If the beneficiary sees a non-network provider, the provider can choose to participate or not: Participating providers may submit claims for beneficiaries, but are not required Non-participating providers are not required to file and may choose not to submit a claim for the beneficiary Beneficiaries should ask and verify that their civilian providers will file the claim o