Billing with Unlisted
Procedures
Some procedures may not be found in any level of Healthcare Common
Procedure Coding System (HCPCS). Typically, these are services that
are rarely provided, or are unusual, variable, or unlisted procedures. In
order for TriWest to make an appropriate benefit determination,
prior authorization for all unlisted codes is required. If the
unlisted code is approved, claims must be submitted with a description of
the service/item or a National Drug Code (NDC) and will be reimbursed
according to the TriWest Fee Schedule found at www.triwest.com/provider under
the “Reimbursement Rates” link.
Claims submitted with
unlisted codes that do not have prior authorization will be denied. If
claims are received with documentation but were not authorized,
reimbursement will be reduced by at least 10 percent for noncompliance
with the authorization requirement.
Timely Filing
Network providers, by
virtue of their contracts with TriWest, should make their best efforts
to file all claims within 30 days. TRICARE requires that all claims
be submitted to TriWest 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 or one year from the date of discharge
for an inpatient admission.
