Navigating healthcare options and ensuring continuous coverage can often be a complex task, especially for military families and veterans. The TRICARE Prime Reconsideration Request Form serves as a crucial tool for those in the defense community seeking to reinstate, reenroll, or retroactively enroll in TRICARE Prime coverage. This detailed form requires sponsors to provide personal information, including Social Security or Defense Enrollment Eligibility Reporting System (DEERS) Beneficiary Numbers, addresses, and contact details. It demands a clear specification of the requested action—whether to reinstate, reenroll, or retroactively enroll coverage, alongside a detailed explanation for reconsideration. The form also touches on the importance of submitting supporting documentation, such as proof of payment or written documentation, to bolster the request. Signature requirements underscore the seriousness of the request, emphasizing that processing will not commence without it. Additionally, the form includes provisions for setting up electronic payments for monthly premiums, highlighting options for Electronic Funds Transfer (EFT) or Recurring Credit Card (RCC) payments to UnitedHealthcare Military & Veterans. By threading through the complexities of maintaining healthcare coverage, the TRICARE Prime Reconsideration Request Form embodies a vital resource for those affiliated with the military, ensuring that healthcare coverage is a right, not a complication, in their lives.
| Question | Answer |
|---|---|
| Form Name | Tricare Prime Request Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | UHCMV0895_10072 013_Prime Reconsideration Request Form_v4.1 uhcmv0895 form |
TRICARE Prime
Reconsideration Request Form
Please type or print all entries.
TRICARE Prime Sponsor Information
Sponsor Name: Last |
First |
M.I. |
Sponsor SSN or DBN
Home Address: Street |
Apt. No. |
City |
State |
ZIP Code |
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Mailing Address: Street |
Apt. No. |
City |
State |
ZIP Code |
If different then above |
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Sponsor |
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Day Time Phone Number:
Evening Phone Number:
Step 1: Please specify the action you are requesting.
☐Please Reinstate coverage. If approved, your coverage will be continuous from your last paid through date once enrollment fees have been paid current. If approved, claims for health care services received during your disenrollment would then be processed under TRICARE Prime.
☐Please Reenroll coverage. If a lockout waiver is approved, you must purchase new coverage by submitting a new TRICARE enrollment form. Any claims for health care services received during your disenrollment must be covered by the beneficiary or the existing coverage at time of service.
☐Please Retroactively Enroll coverage. For emergency cases that should be placed under immediate case management, exceptions may be made on a
Step 2: Please provide a DETAILED explanation & list each person to be reinstated/reenrolled/retroactively enrolled.
Detailedreasonforreconsiderationisrequired. Ifmorespaceisneeded,pleaseattachanadditionalpage.
Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.
TRICARE West Region Customer Service:
“TRICARE” and “TRICARE Prime” are registered trademarks of the Defense Health Agency. All Rights Reserved.
UHCMV0895_10282013 |
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TRICARE Prime
Reconsideration Request Form (Continued)
Beneficiariestobereenrolled/reinstated:
Please note: If you have been disenrolled for failure to pay your TRICARE enrollment fees, TRICARE policy states that you will be unable to enroll for 12 months.
Step 3: Please provide supporting documentation as applicable.
Proof of payment, fax confirmation, written documentation and/or print outs etc.
Step 4: Sign Request Form Signature must be of sponsor, spouse or other legal guardian of beneficiary.
Signature________________________________________________________________ Date___________________
**Request will not be processed without a signature**
Step 5: Please mail or fax to the address below.
Mail this form to: |
or Fax this form to: |
UnitedHealthcare Military & Veterans |
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TRICARE West Region Enrollment Department |
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P.O. Box 105492 |
THANK YOU FOR YOUR SERVICE! |
Atlanta, GA |
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Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.
TRICARE West Region Customer Service:
“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select,” and “TRICARE Retired Reserve” are registered trademarks of the
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TRICARE Management Activity. All Rights Reserved. |
UHCMV0895_XXXX2013 |
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Electronic Payment Authorization Form
Reconsideration Purpose Use Only
Please type or print all entries.
TRICARE Prime Electronic Payment Authorization Form
Sponsor Name: Last |
First |
M.I. |
Sponsor SSN or DBN
Home Address: Street |
Apt. No. |
City |
State |
ZIP Code |
Step 1: Please select the method of payment option you wish to start below.
☐Electronic Funds Transfer (EFT) Please begin automatic payments of my monthly premiums payable to UnitedHealthcare Military & Veterans by means of Electronic Funds Transfer from my financial institution.
Please check one: ☐ Checking ☐ Savings |
(Note: Please attach voided check) |
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____________________________ |
______________ ____ |
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Name of Financial Institution |
9 Digit Bank or ABA Routing Number |
Account Number |
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☐Recurring Credit Card (RCC) Please begin automatic payments of my monthly premiums payable to UnitedHealthcare Military & Veterans by means of Recurring Credit Card from my financial institution.
Please check one: ☐ Visa ☐ MasterCard ☐ Discover |
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__ __/__ __ (MM/YY) |
16 Digit Credit Card Number |
Expiration Date |
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Step 2: Authorize this request with your signature and mail to the address below.
My signature authorizes UnitedHealthcare Military & Veterans to start automatic monthly payments using the method selected in Step 1 above to deduct my premiums due as determined by TRICARE. This agreement will remain in full force unless cancelled by me in writing or by my financial institution or UnitedHealthcare. I understand that a $20.00 administrative fee will be assessed for any payments returned due to insufficient or unavailable funds.
Authorized Signature (Required): |
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Date: _____ ____ |
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Mail this form to: |
or Fax this form to: |
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UnitedHealthcare Military & Veterans |
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TRICARE West Region Enrollment Department |
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P.O. Box 105492 |
THANK YOU FOR YOUR SERVICE! |
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Atlanta, GA |
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Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.”
Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.
TRICARE West Region Customer Service:
“TRICARE” and “TRICARE Prime” are registered trademarks of the Defense Health Agency. All Rights Reserved.
UHCMV0895_10282013 |
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