APTA Advisory: Check With Your TRICARE Contractor About PTA Services and Billing

A change in TRICARE coverage long advocated by APTA officially launches on April 16 — but that doesn’t mean claims will be accepted right away.

Technically, it’s true: beginning with date of service on April 16, physical therapist assistants and occupational therapy assistants will be included as authorized providers under TRICARE, the health insurance system used throughout the military — and thus eligible for reimbursement for covered services rendered to TRICARE beneficiaries. The TRICARE website even says as much.

But according to Kara Gainer, APTA’s director of regulatory affairs, before you begin submitting claims for covered services provided by PTAs to TRICARE beneficiaries, you may want to first check with your TRICARE contractor.

“We’re telling providers that, yes, the change has occurred and that PTAs are eligible for reimbursement for services rendered beginning on April 16, 2020. However, contractors may not yet have made the necessary systems changes,” Gainer said. “It’s important that providers find out whether their contractors are ready to process the claims and if any new coding requirements are being applied to this change.”

How long of a wait may be in store? In a member alert, the National Association for the Support of Long Term Care quotes the U.S. Defense Health Agency as saying that while PTAs and OTAs are eligible for full reimbursement, “full implementation will occur approximately 30-90 days after the effective date.”

Until the policy language is published in the TRICARE manual and adopted by the contractors, PTs and PTAs should plan to follow Medicare’s rules for supervision and reimbursement, which the Department of Defense outlined in the final rule, according to Gainer. Providers who send in claims for dates of service beginning on or after April 16 and receive a denial can resubmit, she advises, but simply checking with the contractor beforehand could reduce later hassles.

In Gainer’s opinion, the delayed implementation, while frustrating to some, is worth the wait.

“This is a major step forward for TRICARE and the focus of significant APTA advocacy efforts,” Gainer said. “Once the contractors’ systems catch up with the shift, we look forward to increased patient access to effective care through the services of PTAs.”