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New TRICARE East Region Billing/Rendering EDI Provider Edits—Effective Jan. 12, 2019.


WPS Military and Veterans Health EDI front-end editing changes for TRICARE East Region 837 Professional claims, effective Jan. 12, 2019. Historically, many claims pend in the claims processing system because they were submitted with an incorrect Billing Provider Name and/or National Provider Identifier (NPI), or the rendering provider segment is missing when a clinic submitted the claim.

WPS notified you of changes to the EDI front-end and allowed you, our trading partners, time to implement changes. WPS will be using the National Plan and Provider Enumeration System (NPPES) as the resource for validating NPI data, therefore it is important that provider’s review their NPPES records for accuracy. The NPPES resourced data will be updated monthly, by the 22nd of each month.

The following edits will be applied to 837 Professional claims only when:

  1. NPI in Billing and/or Rendering Provider Segment(s) is valid.
  2. A Billing NPI is submitted in NM109 of the 2010AA Billing Provider Loop, with place of service 11 (office) only:
    • If the NPI submitted is a Type 1, then the Sole Proprietor field must be a Yes.
    • If the NPI submitted is a Type 2, then the Rendering Provider Segment must be submitted in Loop 2310B or 2420A.

    • Note: The Rendering Provider NPI will not be required at this time, but the segment must be provided with the Rendering Provider Name.

  3. As a reminder, the Billing Provider Address Loop 2010 must have a physical address. If the services rendered were not at this address, then the Service Facility Loop 2310C must be submitted. If there is more than one Service Facility for the claim, then use the Service Facility Loop 2420C.

Error messages on your 277CA claims acknowledgment and suggested resolutions

  • STC*A7:562:85—Invalid Billing NPI. Verify the billing provider NPI is valid. If valid, verify it is active on NPPES.
  • STC*A8:562:85—Invalid billing provider relationship. Verify the billing provider is a solo practitioner or an organization. If the billing provider is a member of a group, the group’s information, including NPI, should be in the 2010AA; and rendering provider information in 2310B or 2420A. If you are a solo practitioner, update your NPPES record.
  • STC*A8:562:82—Invalid rendering provider relationship. Verify that the rendering provider NPI is present. Rendering provider is required for taxonomy codes Multi-Specialty—193200000X and Single Specialty —193400000X. 
  • STC*A7:562:82—Verify the rendering provider NPI is valid.  If valid, verify it is active on NPPES.

*Please note, claims may have previously pended and processed (including payment). 

 

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