Resolved Tricare billing/pricing

[CarrieL_60331]

I'm looking for help with Tricare billing and the 15% up-charge for non-network providers.
Thanks

 

[Lori]

Thanks for coming to the new forum! @Jennifer can you assist with this question?

 

[Jesus]

I'm looking for help with Tricare billing and the 15% up-charge for non-network providers.
Thanks

What exactly is your question so Jennifer can respond when she sees this post?

 

[CarrieL_60331]

I have been told that the 15% up-charge is only for approved/payable Tricare services. I'm wondering if that is true and/or how it would apply to infertility services. I can't seem to get a clear answer if this would be based on diagnosis codes which then leads me to question if fertility testing (Z31.41) is a covered service.

 

[JessieT_49360]

I have worked for 18 years billing/collecting and based on my experience most health insurance companies do not cover infertility and some other cover infertility related diagnostic testing but not procedures. They do base it on the diagnosis. Knowing the member's/patient's benefits is essential since sometimes even when the service is covered you will still need authorization or to have an LOA on file specially if the services were rendered by a non-par provider.
Hope this helps

 

[CarrieL_60331]

I have worked for 18 years billing/collecting and based on my experience most health insurance companies do not cover infertility and some other cover infertility related diagnostic testing but not procedures. They do base it on the diagnosis. Knowing the member's/patient's benefits is essential since sometimes even when the service is covered you will still need authorization or to have an LOA on file specially if the services were rendered by a non-par provider.
Hope this helps

Being a Non-Par Tricare Provider we don't check coverage. We do abide by the balance bill amount of 115% of the Tricare allowable. Being that some of our procedures/visits are GYN based, fertility testing and/or infertility treatment I get myself confused sometimes. I know to apply the 115% to the GYN visits and anything infertility related is charged our "cash" price since it's not a Tricare covered service. The fertility testing (Z31.41) is where I'm second guessing if it's a "covered service" or not .... so I know know how to bill the patients.

 

[JessieT_49360]

Being a Non-Par Tricare Provider we don't check coverage. We do abide by the balance bill amount of 115% of the Tricare allowable. Being that some of our procedures/visits are GYN based, fertility testing and/or infertility treatment I get myself confused sometimes. I know to apply the 115% to the GYN visits and anything infertility related is charged our "cash" price since it's not a Tricare covered service. The fertility testing (Z31.41) is where I'm second guessing if it's a "covered service" or not .... so I know know how to bill the patients.

The best way to know if the service is a covered benefit or not is to call Tricare otherwise you can bill them and wait for the EOP. It will give you the reason for the denial if you don't know the patient's/member's benefits.

Best of luck

 

[Alicia]

Awesome feedback guys. I learned something.

 

[Jennifer]

Fertility treatments (I believe) are a covered benefit with Tricare, however at MTFs (Medical treatment facilities). As a non-participating provider, a non-covered benefit would be the patient's responsibility. Unless you are able to obtain the dollar amount prior to the visit (through a web verification system with the codes) waiting for the RA/EOB/EOR would be the best option to know the amount the patient is responsible for.

 

[CarrieL_60331]

Fertility treatments (I believe) are a covered benefit with Tricare, however at MTFs (Medical treatment facilities). As a non-participating provider, a non-covered benefit would be the patient's responsibility. Unless you are able to obtain the dollar amount prior to the visit (through a web verification system with the codes) waiting for the RA/EOB/EOR would be the best option to know the amount the patient is responsible for.

Thank you. I do know the .mil website where I can check CPT codes by zip code and it will give me pricing info just doesn't allow you to look up by Dx codes also.