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New TRICARE Home IV Requirements Will Fix Claim Denials

(December 1, 2009)

On November 9, TRICARE issued new reimbursement requirements for home infusion claims which direct its contractors to fix the denials of claims that home infusion providers have been experiencing for (1) IV supplies and (2) billings after obtaining Medicare PR-50 denials.

This has occurred after NHIA brought to the attention of the Department of Defense’s agency that administers TRICARE (called TRICARE Management Activity, or TMA) two “hot issue” claim denial situations. We provide each issue followed by the corrective TRICARE requirements published in Chapter 3, Section 6 of the TRICARE Reimbursement Manual. (Words in italics are quotes from the manual.)

Issue #1: When infusion supplies are billed on same date of service as a nursing visit, the supply billings have been denied since October 1, 2008. This resulted from an update of a claim editor used by the TRICARE contractors.

TRICARE Reimbursement Manual: Separate payment will be allowed for supplies that are billed in association with a home infusion visit (e.g., supply codes A4221/A4222/A4223 will be paid separately from associated home infusion visits (Current Procedural Terminology (CPT)1 procedure codes 99601 and 99602)). Claims adjustments will be retroactive back to October 1, 2008 for those providers bringing it to the attention of the contractors.

Issue #2: The TRICARE For Life plan, which covers health care claims secondary to Medicare, has been automatically rejecting claims for home infusion therapy denied by Medicare as not medically necessary—a technical denial based on Medicare statute and coverage policy that hardly ever means the therapy is medically unnecessary.

TRICARE Reimbursement Manual: The TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) contractor will develop all home infusion claims with Medicare denial code PR-50 to determine whether or not the denial code was simply put on the claims because of non-coverage or whether it was used because the services were truly not medically necessary and as such, subject to the provisions under Chapter 4, Section 4, paragraph I.C.1.d. TRICARE should pay as primary if the services are medically necessary. Claims adjustments will be retroactive back to October 1, 2008 for those providers bringing it to the attention of the contractors.

As TRICARE won't initiate payment on past claims automatically, NHIA urges home infusion providers to contact your TRICARE contractor representative to determine procedures for reversing your claim denials.  The TRICARE contractors should have processes in place in December to resolve the denial situations.


1. CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.