Guiding Claims Form – Fill Out and Use This PDF

TRICARE ® Guiding

the Claims Process

TRICARE ® Guiding the Claims Process

This brochure is not all-inclusive. For additional information, please contact your regional contractor, local military treatment facility, or overseas contractor.

In most cases, you will not need to ile claims for health care services, but there may be times when you will need to pay up front and ile a claim for reimbursement. You will be reimbursed for TRICARE-covered services at the TRICARE-allowable amount, less any copayments, cost-shares, and deductibles.

Filing a Claim

In the United States and U.S. territories (American Samoa,

Guam, the Northern Mariana Islands, Puerto Rico, and the

U.S. Virgin Islands), claims must be iled within one year from the date of service or date of inpatient discharge. Outside of the United States and U.S. territories, claims must be iled within three years. To ile a claim, you must complete and sign a

TRICARE DoD/CHAMPUS Medical Claim—Patient’s

Request for Medical Payment form (DD Form 2642), available at www.tricare.mil/claims or your regional contractor’s Web site. Beneiciaries (age 18 or older), spouses, parents, or guardians may sign the initial claim form, though later forms (needed to process a claim) must be signed by the beneiciary (or parent or guardian if child is under 18). Attach a readable copy of the provider’s itemized bill and include:

•Patient’s name

•Sponsor’s Social Security number (SSN) or Department of Defense Beneits Number (DBN) (Eligible former spouses should use their own SSNs, not the sponsor’s.)

•Provider’s name and address (If more than one provider’s name is on the bill, circle the name of the provider who performed the service for which the claim is iled.)

•Date, place, description, and charge of each service

•Diagnosis (If the diagnosis is not on the bill, complete block 8a on the form.)

Send all claims, except TRICARE For Life (TFL) claims and claims for care received overseas, to the claims processor for the region in which you live.

TRICARE For Life Claims

Wisconsin Physicians Service is the claims processor for all TFL claims for care received in the United States and U.S. territories, where Medicare is available. In most cases, your provider should ile a claim with Medicare irst. Medicare pays its portion and forwards the claim to TFL for processing, unless you have other health insurance (OHI). If you have OHI, after Medicare has processed the claim and paid its portion, Medicare will forward the claim to your OHI. If there is a remaining balance after your OHI has processed the claim, you will need to submit the Medicare Summary Notice along with the OHI explanation of beneits (EOB) and the DD Form 2642 for payment. Use DD Form 2642 if iling a TFL claim yourself.

Medicare does not provide coverage outside of the United States and U.S. territories. Therefore, TFL is your primary payer for health care received overseas (except U.S. territories), unless you have OHI. TFL provides the same coverage

as TRICARE Standard and has the same cost-shares and deductibles for beneiciaries who live or travel overseas. Submit claims directly to the overseas claims processing address for the region where you received care.

TRICARE Overseas Claims

If you live in the United States and receive care overseas, be prepared to pay up front for services, then ile a claim with the TRICARE Overseas Program (TOP) claims processor. If you live overseas, you will ile claims with your TOP claims processor regardless of where you receive care.

All beneiciary-submitted claims for care received overseas must include proof of payment. Submit proof of payment, along with the DD Form 2642, to the TOP claims processor. When submitting your DD Form 2642, include one of the following, as applicable:

•An itemized bill or invoice

•A diagnosis describing why you received medical care

•An EOB from your OHI

A canceled check or credit card receipt showing payment for medical supplies or services often satisies the proof-of- payment requirement. If you paid for care or supplies in cash, TRICARE may ask for proof-of-cash withdrawal from your bank or credit union along with a receipt from your provider.

To help facilitate claims processing, write at the top of

DDForm 2642 if payment was made directly to the provider. Note: After submitting the documents listed, you may be asked for additional documentation. Call your TOP Regional Call Center and select option 2 for claims assistance. For more information about the overseas claims process, visit www.tricare.mil/claims.

Coordinating Claims with OHI

Keep your regional contractor and health care providers informed about your OHI so they can better coordinate your beneits and prevent claim-payment delays (or denials). Visit your regional contractor’s Web site to update your OHI information. Follow your OHI’s rules for iling claims irst. If there is a billed amount your OHI does not cover, you can ile a claim with TRICARE. After your OHI pays its portion, submit a copy of your EOB and a copy of the itemized bill with your TRICARE claim. For additional OHI information, visit www.tricare.mil/ohi. Note: TRICARE is the last payer to all health care beneits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs and plans identiied by the TRICARE Management Activity. National health insurance programs overseas are considered OHI.

Filing an Appeal

You may appeal the denial of a requested authorization of services, as well as TRICARE decisions regarding claims payments, by submitting an appeal to your regional contractor. For additional information, visit www.tricare.mil/appeals.

For Information and Assistance

Claims addresses are included below. Claims forms are available from your contractor’s Web site or www.tricare.mil/claims.

	TRICARE North Region	TRICARE South Region	TRICARE West Region
	Health Net Federal Services, LLC	Humana Military Healthcare Services, Inc.	TriWest Healthcare Alliance
	1-877-TRICARE (1-877-874-2273)	1-800-444-5445	1-888-TRIWEST (1-888-874-9378)
	www.hnfs.com (general information)	Humana-Military.com (general information)	TriWest.com (general information and claims)
	www.myTRICARE.com (claims)	www.myTRICARE.com (claims)	West Region Claims
	Health Net Federal Services, LLC	TRICARE South Region Claims Department	P.O. Box 77028
	c/o PGBA, LLC/TRICARE	P.O. Box 7031	Madison, WI 53707-1028
	P.O. Box 870140	Camden, SC 29020-7031
	Surfside Beach, SC 29587-9740
	TRICARE Overseas Program (TOP) Regional	TOP Regional Call Center—Latin America	TOP Regional Call Center—Pacific1
	Call Center—Eurasia-Africa1	and Canada1	Singapore: +65-6339-2676 (overseas)
	+44-20-8762-8384 (overseas)	+1-215-942-8393 (overseas)		1-877-678-1208 (stateside)
	1-877-678-1207 (stateside)	1-877-451-8659 (stateside)		sin.tricare@internationalsos.com
	tricarelon@internationalsos.com	tricarephl@internationalsos.com	Sydney:	+61-2-9273-2710 (overseas)
	TRICARE Overseas Program	TRICARE Overseas Program		1-877-678-1209 (stateside)
	P.O. Box 8976	P.O. Box 7985		sydtricare@internationalsos.com
	Madison, WI 53708-8976	Madison, WI 53707-7985	TRICARE Overseas Program
	USA	USA
			P.O. Box 7985
			Madison, WI 53707-7985
			USA
	TRICARE Active Duty Claims Overseas	TRICARE For Life (TFL)	TRICARE Web Site
	(All regions)	(United States and U.S. territories)	www.tricare.mil
	www.tricare-overseas.com	1-866-773-0404
	TRICARE Active Duty Claims	1-866-773-0405 (TDD/TTY )
		www.TRICARE4u.com
	P.O. Box 7968
	Madison, WI 53707-7968	WPS TRICARE For Life
		P.O. Box 7890
		Madison, WI 53707-7890

1. For toll-free contact information, visit www.tricare-overseas.com.

An Important Note About TRICARE Program Information

At the time of printing, this information is current. It is important to remember that TRICARE policies and beneits are governed by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations are amended. Military treatment facility guidelines and policies may be different than those outlined in this product. For the most recent information, contact your TRICARE regional contractor, TRICARE Service Center, or local military treatment facility.

“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.

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