November 05, 2013
Area(s) of Interest: Practice Management Public Health Vaccination
The California Medical Association (CMA) has received clarification from United Healthcare Military and Veterans Services (UMVS) on an ongoing billing issue involving underpayment of immunizations and injectables for TRICARE members. TRICARE provides coverage for most drugs and immunizations administered in a provider's office and pricing of these immunizations and drugs is based on the corresponding Champus Maximum Allowable Charge (CMAC) rates. Drugs that do not have a CMAC rate established are priced at a percentage of average wholesale price (AWP). In order for AWP to be accurately determined, providers must include the National Drug Code (NDC) number along with the corresponding HCPCS or CPT code when submitting their claim to UMVS.
CMA had identified that some immunizations billed with the appropriate NDC number still resulted in underpayments following the April 1 transition to UMVS. After a lengthy review, UMVS has recently determined that the problem revolves around the omission of the NDC package indicator on provider claims. For each NDC number, you must also include the package indicator and quantity (package vs. units).
UMVS has posted a tip sheet, “Office Immunizations & Injectables Claims Tips for Error-free Processing,” on the uhcmilitarywest.com website for providers seeking clarification on the billing of immunizations and injectables. Practices who believe they were previously paid incorrectly can submit corrected claims to UMVS via fax or mail for payment correction.
Fax corrected claims to: (855) 831-7048
Mail corrected claims to:
TRICARE West Region
PO Box 7065
Camden, SC 29020-7065
It’s important to note that UMVS requires that all corrected claims be stamped “corrected claim” in order to be reprocessed correctly. Those that are not will be denied as duplicates.
Providers who have additional questions should contact UMVS at (877) 988-9378.