Tricare North Region Provider Handbook

Purpose of the Handbook

The Tricare North Region Provider Handbook is the official guide that explains the policies, procedures, and responsibilities of healthcare providers who deliver services to Tricare beneficiaries in the northern United States. It consolidates regulations from the Department of Defense (DoD), the Defense Health Agency (DHA), and the Tricare Management Activity (TMA) into one accessible reference.

Key objectives include:

• Clarifying eligibility determination and enrollment processes.
• Standardizing claim submission and reimbursement practices.
• Describing referral, prior authorization, and utilization management pathways.
• Outlining documentation standards to support medical necessity.
• Providing contact information for technical assistance and dispute resolution.

Who Uses It?

The handbook is intended for:

• Physicians, dentists, optometrists, and other clinical professionals.
• Hospital administrators and billing staff.
• Pharmacy and laboratory service providers.
• Case managers, utilization review nurses, and healthsystem compliance officers.

Even though Tricare North covers a specific geographic region (the six states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), many providers outside the region encounter Tricare patients through referrals or telehealth services, making the handbook valuable nationwide.

Handbook Structure

The document is divided into ten chapters, each addressing a core area of provider interaction with the program. The chapters are:

1. Introduction and Scope
2. Eligibility & Enrollment
3. Beneficiary Classes
4. Billing & Claims Processing
5. Referral and Authorization Requirements
6. Allowed Services and Covered Benefits
7. Documentation and Coding Standards
8. Payment Policies and Rates
9. Compliance, Audits, and Investigations
10. Appendices (Glossary, Contact Lists, Forms)

Each chapter contains a brief overview, detailed policy statements, illustrative examples, and frequently asked questions (FAQs). The handbook is available in PDF, searchable HTML, and mobileoptimized formats.

Eligibility & Enrollment

Eligibility determination is the first step before any services are rendered. The handbook outlines three primary beneficiary categories:

• Active Duty and Retired Military automatically eligible.
• Family Members spouse, children, and certain dependents, subject to enrollment.
• NonUniformed Survivors eligible under specific conditions such as death benefits.

Providers must verify enrollment status using the TRICARE Online Portal (TOP) or by contacting the Regional Tricare Management Activity. The verification step must be documented in the patients chart before the first encounter.

Billing & Claims

All claims for Tricare North must be submitted electronically through the Defense Health Billing System (DHBS) or an approved clearinghouse. The handbook specifies the required data elements, including:

• Beneficiary ID (Tricare ID number)
• Provider Tax Identification Number (TIN)
• Current Procedural Terminology (CPT) codes
• Healthcare Common Procedure Coding System (HCPCS) modifiers
• Diagnosis codes (ICD10CM)
• Place of service (POS) indicator
• Charges and units of service

Claims must be submitted within 90 days of the date of service (DOS). Late submissions are subject to automatic denial unless a documented extenuating circumstance is provided.

The handbook also details the PayTo process for indirect care settings (e.g., community hospitals) and clarifies when the provider should bill the patient directly for noncovered items.

Referrals & Authorizations

Specialist visits, diagnostic imaging, and certain procedures require a referral or prior authorization (PA) from a Tricare-authorized primary care manager (PCM) or a designated referral manager. The handbook provides a stepbystep flowchart:

1. Provider identifies need for specialty care.
2. Submit referral request via the TRICARE Referral System (TRS) with supporting documentation.
3. PCM reviews and either approves, denies, or requests additional information.
4. Once approved, the provider receives a referral number to be entered on the claim.

Urgent care and emergency services are exempt from prior authorization, but the referral still must be documented retrospectively when possible.

Documentation Requirements

Accurate and complete documentation is essential for claim acceptance and audit readiness. The handbook mandates the following for all encounters:

• Patient identifiers and date of service.
• Chief complaint and history of present illness.
• Physical examination findings.
• Assessment and plan, including medical necessity rationale.
• Signed and dated provider signature (electronic or handwritten).

For surgical procedures, a separate operative report is required, and for radiology studies, a detailed interpretation must be included.

Retention period: records must be maintained for at least six years from the date of service, in accordance with DoD regulations.

Compliance & Audits

Tricare North conducts routine compliance reviews and random audits. The handbook outlines the providers obligations during an audit:

• Provide requested documentation within the stipulated 30day window.
• Maintain a pointofcontact (POC) for audit communication.
• Submit corrected claims if errors are identified.
• Cooperate with investigative teams and refrain from destroying or altering records.

Failure to comply can result in payment recoupments, civil penalties, or exclusion from the Tricare network.

Helpful Resources

Below are frequently used tools referenced in the handbook:

• Tricare Online Portal (TOP) eligibility verification, enrollment updates, and claim status.
• TRICARE Referral System (TRS) electronic referral and authorization submission.
• Defense Health Billing System (DHBS) claim entry and tracking.
• Provider FAQ Library searchable collection of common questions.
• Contact Center 18004442737 (option 2) for live assistance.

How to Stay Updated

The handbook is revised annually, with interim updates released as Policy Bulletins. Providers should:

1. Subscribe to the Tricare North Provider Newsletter.
2. Regularly check the Updates tab on the Tricare provider website.
3. Attend quarterly webinars hosted by the Regional TMA.
4. Review the Change Log included at the end of each PDF version.

Implementing the latest guidance promptly helps avoid claim denials and ensures compliance with current regulations.