Tricare

Tricare/CHAMPVA EOB Remark Codes

Claims in "S" status --- Please check the paid to date. We must have enough premium to cover the DOS.

If we do NOT have enough premium please explain to the member we need all back premium. If you are speaking to the provider explain we need to speak to the member.

If we have enough premium please send the claims template to claims and advise the paid to date & please reconsider the claims.

Timely Filing Limit is 24 months from the primary processing date. 

 

Remark Code
Description
01 Charges prior to your effective date are not covered.
02 Charges after your termination date are not covered. 
03 No coverage in force. Dates of service fall within coverage gap.
04 TRICARE reduced payment for failure to obtain Pre-Authorization. The provider cannot bill for the difference.
05 This is a non-covered expense under your plan. 
06 Plan pays inpatient charges only.
07 Plan pays TRICARE prime co-pays only.
08 This claim is currently on file pending pre-existing condition investigation. Information has been requested from the member or provider.
09 Dental expenses are not covered. 
10 Pharmacy receipt shows the total cost. Submit TRICARE co-pay receipt or Explanation of Benefits for reimbursement.
11 Pharmacy submission must include the name of drug, prescribing physician, date, fee, and co-pay.
12 CHAMPVA eligible charges for Mental/Nervous conditions are limited to amount specified in your policy. Benefits are exhausted.
13 Catastrophic Cap reached. Cost shares and deductibles no longer apply. Submit your TRICARE/CHAMPVA annual benefit summary for a review.
14 This is your Excess Benefit. 
15 Please submit an itemized bill for services rendered by this provider. 
16 The CHAMPVA Explanation of Benefits is required for further consideration of prescription charges. 
17 MEDICARE eligible beneficiaries are not eligible for coverage. 
18 Claim previously processed. Any benefit due was issued to provider.
19 Claim previously processed. Any benefit due was paid to member.
20 Submit diagnosis for charges. 
21 Pre-existing conditions prior to your effective date are not covered. See Pre-Existing Condition provision of your policy. 
22 Pre-existing conditions prior to the effective date of your increased benefits are not covered. See Pre-Existing Condition provision of your policy. 
23 Please submit proof of payment to provider over $1000 in order to reimburse member.
24 Patient name and date of birth do not match our records. Please resubmit.
25 Your hospital charges cross calendar years. Please submit a complete breakdown of TRICARE/CHAMPVA benefits, including billed amounts, allowed amounts, paid amounts and co-insurance amounts, for each year.
28 Amount paid by primary payer.
29 Reimbursement of the standard TRICARE Rx copay. 
30 Plan deductible amount. 
31 Charges previously considered and applied to plan deductible. 
32 The charges were previously denied as your policy does not reimburse the TRICARE/CHAMPVA deductible.
33 TRICARE/CHAMPVA deductible not covered. 
34 The maximum TRICARE deductible benefit covered under this policy has been exhausted. The charge(s) are patient responsibility. 
35 The TRICARE Point of Service deductible is not a covered expense under your plan.
36 The maximum TRICARE deductible covered under your plan was applied to your plan deductible
40 This is an adjustment audit to consider additional benefits.
41 The charges previously denied have been reconsidered and the attached check represents the benefits.
50 This plan supplements TRICARE/CHAMPVA only. 
51 Please submit the corresponding TRICARE/CHAMPVA Explanation of Benefits for consideration for your claim.
52 The TRICARE/CHAMPVA Explanation of Benefits is incomplete. Submit original for further consideration of your claim. 
53 Duplicate charges previously considered. 
54 Claims must be submitted within 24 months of the TRICARE/CHAMPVA process date. 
55 Your policy does not provide benefits for services denied by TRICARE/CHAMPVA.
56 TRICARE/CHAMPVA denied as duplicate. Submit the original statement showing payment.
57 Charges were paid in full by TRICARE/CHAMPVA; no payment is due.
58 The TRICARE/CHAMPVA EOB received is illegible. A better copy is required for further processing of your claim.
59 TRICARE coverage is not compatible with your Hartford TRICARE supplemental coverage.  Please contact your premium administrator to research and resolve this issue.
60 Charge represents payment by your Other Insurance Carrier.
61 The TRICARE/CHAMPVA Explanation of Benefits does not indicate a cost share or copayment to be considered. 
62 File your claim with your TRICARE contractor for reimbursement.
70 Benefits not assigned to provider; Tax ID number and/or addresss missing.
71 Your claim was separated for processing purposes. You will receive more than one Explanation of Benefits.
72 Due to lack of response to our request for additional information, your file is being closed. Letter of explanation will follow.
73 A letter of explanation will follow under separate cover. 
99 Within 180 days after receipt of this Explanation of Benefits, you may request a review of the handling of this claim in connection with charges which were denied in accordance to plan provisions and limitations. If there are any such questions, please submit your comments in writing, or request a review of pertinent documents upon which the decision was based, and the matter will be given further consideration. Be sure to refer to the Claim Submission Number.

 


 


MD

APPEALS PROCEDURE NOTICE:  If you feel your claim has been improperly denied, you have the right to file an appeal with the Company.  We are available to discuss with you the position we have taken on your claim.  You may reach us at: Selman & Company, P O Box 29151 Hot Springs, AR 71903-3351Toll Free Phone: 1-800-638-2610 x255,  Facsimile: 1-800-310-5514,  Email address: memberservices@selmanco.com.  


You may file a complaint with the Maryland Insurance Administration without filing an appeal with the Company if the coverage decision involves an urgent medical condition for which care has not been rendered.  The Health Advocacy Unit is available to assist in mediating and filing an appeal.  The contact information for the Maryland offices is shown below for your convenience.


The Maryland Insurance Administration:  Maryland Insurance Administration, Appeal and Grievance Unit. 200 St. Paul Place, Suite 2700, Baltimore, Maryland 21202

Phone: 410-468-2000,  Toll Free: 1-800-492-6166, Facsimile: 410-468-2270


Health Advocacy Unit:  Maryland Health Education and Advocacy Unit, Consumer Protection Division, Office of the Attorney General, 200 St. Paul Place – 16th Floor, Baltimore, Maryland 21202

Toll Free Phone” 1-877-261-8807, Hot Line Number: 410-528-1840, Facsimile: 410-576-6571, 

E-mail address: consumer@oag.state.md.us

NY

You can resolve most questions about our processing decisions by calling our Customer Service Department at 1-800-638-6210 x255.  If you still have concerns you have a right to file a written appeal with us.


Write to us and tell us why you disagree with our decision.  Please submit your written appeal to us within 180 days and provide any documentation or medical records that you feel may have a bearing on our decision.  We will notify you in writing with: a request for additional information or; our decision within 30 days of the date we receive your written appeal request.


Should you wish to take this matter up with the New York State Insurance Department, you may write to or visit the Consumer Service Bureau, New York State Insurance Department at:

25 Beaver Street, New York, NY 10004, Agency Building One; Governor Nelson A Rockefeller Empire State Plaza, Albany, NY 12257; Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202

WI

APPEAL OF CLAIM DENIAL:  The Covered Person or his representative has the right to appeal the denial of any benefits for a claim under this Policy.  To appeal a denial, the Cover Person or his representative must submit a written request for a review of the benefit denial.  The request should be accompanied by any supporting material and mailed to Selman & Company, P O BOX 29151 Hot Springs AR 71903-3351.  Within 30 days after receiving the request, Selman & Company will notify the Covered Person his representative of the result of this review.




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