TRICARE Claims Denied Due to Non-Certification of the Provider

For some time the U.S. Military Retirees of the Philippines group has been aware that a large number of TRICARE claims are denied on the basis that the provider of care was not certified. We have had numerous reports of claims denied on this basis but where the beneficiary, on questioning the provider, discovered the provider was never contacted by the contractor, International SOS (ISOS). However, they reported to the claims contractor Wisconsin Physician Services (WPS) that the provider declined certification or could not be found.

A recent incident involved two providers who ISOS reported that the providers could not be found even though both providersí addresses were correctly included with the claim. It seems ISOS, for whatever reason, went to an entirely different location and when they couldnít find the providers simply denied certification on the basis the providers could not be found.

Our group perused this with an employee of TMA, even showing them that a 30 second search of a common physician search engine in the Philippines showed both providers at the addresses that were reported to the claims contractor but where ISOS failed to go. Our point was, even if ISOS made a mistake and went to a wrong location, they should not simply give up but make some effort to locate the provider as 99% of the claims submitted by beneficiaries for care are legitimate and the provider really does exist. The current practice results in thousands of dollars in claims denied each year for legitimate care.

As the result of this specific incident they have agreed to look more closely at the process where providers are not certified and claims denied. However they are asking for our help by providing them with information on claims that fit this profile. If you have a claim that was denied for reason code 018, 129 or 135, all indicating the provider was not certified please consider providing us with the information below.

There are two benefits to doing this. First, if your claim was denied because they claimed they couldnít find the provider or because they claim the provider declined certification and you can confirm that the provider was not contracted; your claim may now be relooked and paid. Second, if we can show enough proof of this occurring the process may be changed to stop or reduce these problems in the future.

The information, indicated below, should be emailed to Jim Houtsma at Jimh44@gmail.com or to U.S. Military Retirees of the Philippines at us_mil_ret_of_the_pi@123mail.org .

1 - Patientís name:
2 - Claim number:
3 - Date denied (Date of notice on EOB):
4 - Date of care:
5 - Denial reason code (018 PROVIDER NOT TRICARE AUTHORIZED FOR THIS SERVICE, 129 PROVIDER NOT TRICARE-AUTHORIZED FOR THIS SERVICE, 135 PROVIDER IS NOT TRICARE AUTHORIZED.):
6 - Full name of provider:
7 - Address of provider submitted with the claim, e.g. complete address on receipt or invoice:
8 - Short narrative indicating if you know if the provider was contacted by ISOS or what you do know about the certification process contact between your provider and ISOS: