Key Updates for Providers as Humana TRICARE Transitions to PGBA in 2025

Humana Military will transfer all claim work to PGBA LLC effective January 1, 2025. Transitioning to this DHM system will highly influence the healthcare domain of TRICARE’s east region for the better, and a good understanding of this transition is needed for easy claim submission & reimbursement. Healthcare providers should be mindful of the information this blog post outlines to ensure a smooth transition.

What is new?

The most profound change is the claim processor relocation. The claim processor used to be Wisconsin Physicians Service (WPS) but has now changed to PGBA LLC. Claims for TRICARE East will have to be relocated, which means that starting in 2025, all providers will need to change where they send their claims.

Important Dates and Deadlines:

PGBA LLC is formally appointed as the new claims processor for TRICARE East on January 1, 2025.

New claims (for dates of service on or after January 1, 2025) should be submitted by providers to PGBA LLC beginning January 1, 2025.

Re-enroll in Electronic Funds Transfer (EFT) with PGBA on January 1, 2025, regardless of whether you are already enrolled with WPS.

The deadline for submitting claims to WPS with a 2024 date of service is April 30, 2025. All claims, regardless of the date of service, must be submitted to PGBA LLC after this date.

What do providers need to do?

There are certain steps that healthcare providers must take when transitioning to the new system. Claim filing will be much smoother if practices ensure the new payer ID (99727) along with the new claims processor, PGBA LLC, is entered into the invoicing software and practice management systems. To avoid claim denial, one must adjust to these changes.

• Be sure to direct your claims to the correct entity: All payments for services rendered from the 1st of January, 2025, must be forwarded to PGBA LLC. These claims should never be forwarded to WPS.
• You will have to re-enroll with PGBA LLC, which is currently a WPS member, most importantly by the 1st of January, 2025. This guarantees uninterrupted payment processing. Also, do not forget that your details for EFT will not be considered to have changed by default.
• Ensure your administrator and billing personnel are aware and trained on these changes as well as the submission of TRICARE East claims. They may need training.
• Do follow up on any related communications and changes from Humana Military and TRICARE. Routinely check the Humana Military and TRICARE sites for further information and guidance.

What does this mean?

Claims being sent to the wrong processor or pertinent information that is no longer current might greatly impede the payment process and possibly result in claim denials. Taking the necessary steps now will ensure that your practice is adequately prepared to streamline these processes in the future.

Where to Locate Additional Details:

• Humana Military Provider Updates
• TRICARE Newsroom

Do not delay! Take the necessary steps in advance in order to avoid interruptions in the billing cycle. By taking these proactive steps, you will make certain that your practice meets all requirements regarding the transition as well as timely billing of services provided to TRICARE beneficiaries.

FAQ

What is the status of TRICARE in 2025?

Palmetto GBA (PGBA) will take over the administration of TRICARE in 2025 after the current TRICARE contractor for the East Region, Humana Military, transitions out. That means PGBA will become the TRICARE administrator for the East Region.

What is the official date of the transition?

An exact date has not been announced yet, but the transition is expected to happen at some point in 2025. Make sure to watch for news releases from Humana and TRICARE.

How will beneficiaries be impacted by this transition?

Most of the services and claims procedures offered will remain intact, and almost all of the administrative processes will go completely unnoticed by the main TRICARE beneficiaries. As always, beneficiaries will receive the needed care. However, some changes may be instituted about policies governing provider directories or submission of claims.

What steps do I need to take in order to prepare for the transition?

Stay updated: Throughout the transition, actively and consistently follow up on any correspondence from Humana, TRICARE, and PGBA.

Credentialing: Make sure that you have a PGBA. Prior to the change, details on how credentialing will be done will be made available to you.

Contracting: You may need to form a new contract with PGBA, so stay alert for change notifications on the contract and its requirements.

System Updates: Prepare your billing and practice management systems for potential modifications to contact information, EDI requirements, and claims submission processes.

Training: Attend any training sessions provided by PGBA or TRICARE regarding the new processes and systems.

Will my current Humana TRICARE contract be automatically transferred to PGBA?

Your current contract is unlikely to automatically transfer. You should expect a new contract with PGBA to be created.

Who can I talk to regarding the transition if I have any questions?

For any immediate issues or questions, please continue to use your existing Humana TRICARE contacts. As the transition nears, PGBA will develop contact points for provider inquiries. Keep an eye out for these notices. The TRICARE website also has contact information and resources.

What is the latest source of information related to the transition?

• TRICARE (www.tricare.mil) is one of the organizations whose performance may be tracked through their websites.
• Humana Military (updated info on provider portal)
• Palmetto GBA (www.palmettogba.com): Search for TRICARE information if and when it becomes available.

Will this be a revenue shuffle—an adjustment to reimbursement rates?

The change in administration is not expected to affect reimbursement rates. However, it is very important that you contact PGBA and confirm what the terms of your new contract will be.