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.
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.
A request for an exception to the claims filing deadline may be submitted by participating providers who are registered users of www.triwest.com/provider using the online claims correspondence tool for consideration on a case-by-case basis. Appropriate attachments can be electronically attached to the online claims correspondence. If online submission is not an option, a letter and copy of the claim may be submitted to:
Wisconsin Physicians Service
ATTN: Timely Filing Waiver Request
P.O. Box 77029
Madison, WI 53707-1029
TriWest reviews and gives individual consideration to each case.
After the proper claim has been submitted and an exception to the claims filing deadline granted, TriWest considers only those services or supplies received for a six-year period immediately preceding
the receipt of the request.