Since February, the AOA Third Party Center and the VOA have received several notifications from members of continued claims denials from Tricare/HNFS related to E&M CPT Codes.

We recently received confirmation that while the policy has been corrected, “the IT intervention to correct the automated processing of E&M claims is proving to be more of a challenge than anyone expected….”  As a result, some (a few) denials are still occurring as the claims vendor continues to work to update their system.

Optometrists who receive these denials should see them reversed within 12 to 15 days of receiving a denial.

For those who receive a denial in the future for a higher level E&M code, please note that instead of following the appeal-process outlined in the earlier document, HNFS now suggests that ODs wait at least two weeks before taking any action so that the claims sweeps can occur and corrective payments can be made. For claims still not paid after two weeks, HNFS recommends calling the PGBA (claims vendor) External Routine Line 877-874-2273 and request that the claim be reprocessed.