Guiding Claims Form PDF Details

Are you going through the complicated process of filing a claim? Are you confused and overwhelmed by all the paperwork involved in submitting a successful claims form? It doesn't have to be as intimidating as it may first seem. By following this simple guide, you will learn how to effectively complete and submit your claim forms so that you can get what is rightly yours. This blog post gives useful advice on how to successfully navigate the claims-filing process, from filling out crucial information to understanding instructions and submitting documents correctly. Keep reading for helpful tips on filing your claim form today!

Form NameGuiding Claims Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namestricare guiding online, form 2642, guiding claims process, dd form 2642 fillable

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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 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.

August 2012

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

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 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

For Information and Assistance

Claims addresses are included below. Claims forms are available from your contractor’s Web site or

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)


1-888-TRIWEST (1-888-874-9378) (general information) (general information) (general information and claims) (claims) (claims)

West Region Claims



Health Net Federal Services, LLC

TRICARE South Region Claims Department

P.O. Box 77028


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)


+61-2-9273-2710 (overseas)



TRICARE Overseas Program

TRICARE Overseas Program


1-877-678-1209 (stateside)

P.O. Box 8976

P.O. Box 7985

Madison, WI 53708-8976

Madison, WI 53707-7985

TRICARE Overseas Program



P.O. Box 7985





Madison, WI 53707-7985








TRICARE Active Duty Claims Overseas



(All regions)

(United States and U.S. territories)




TRICARE Active Duty Claims

1-866-773-0405 (TDD/TTY )



P.O. Box 7968






Madison, WI 53707-7968





P.O. Box 7890




Madison, WI 53707-7890







1. For toll-free contact information, visit

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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1. Whenever filling in the dd form 2642 fillable, make sure to complete all of the important blanks in their corresponding part. This will help to facilitate the work, enabling your details to be handled fast and accurately.

Simple tips to fill out guiding claims portion 1

2. Now that this part is finished, you should insert the essential details in A canceled check or credit card, To help facilitate claims, Keep your regional contractor and, Filing an Appeal, You may appeal the denial of a, For Information and Assistance, TRICARE North Region Health Net, Health Net Federal Services LLC co, TRICARE South Region Humana, TRICARE South Region Claims, TRICARE West Region TriWest, and West Region Claims PO Box Madison in order to move on further.

Filling in section 2 of guiding claims

Lots of people often make mistakes when completing Health Net Federal Services LLC co in this section. Be sure to revise whatever you type in here.

3. Completing TRICARE Overseas Program TOP, TOP Regional Call CenterLatin, TRICARE Overseas Program PO Box, TRICARE Overseas Program PO Box, TRICARE Active Duty Claims, TRICARE Active Duty Claims PO Box, TRICARE For Life TFL United States, WPS TRICARE For Life PO Box, For tollfree contact information, TOP Regional Call CenterPacific, Sydney, overseas stateside, TRICARE Overseas Program PO Box, TRICARE Web Site wwwtricaremil, and An Important Note About TRICARE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

The way to fill in guiding claims step 3

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