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Claims

Electronic Remittance Advice Enrollment

Use this form to enroll in electronic remittance advice (ERA) for the TRICARE West Region. 

  • Created: Feb 15, 2018
  • Modified: Feb 15, 2018
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Provider Fax Separator Sheet

If you would like to fax claims related information for multiple patients, please use a fax separator sheet between each patient's correspondence. Please do not use photocopies of the fax separator sheet. 

  • Created: Dec 30, 2017
  • Modified: Dec 29, 2017
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Request for Reimbursement of TRICARE Hospice Cap Amount

Use this form to request reimbursement of the TRICARE hospice cap amount for services within the cap period ending Oct. 31, 2018.

Return completed form to:

TRICARE West Region
Attention: FC-3H3
160 Dozier Blvd
Florence, SC 29502
Fax: 843-664-0918

  • Created: Oct 10, 2018
  • Modified: Oct 10, 2018
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National Provider Identifier (NPI) Form

Health Net Federal Services, LLC offers payments and remittances by National Provider Identifier (NPI) number. The NPI billed on the claim will determine where payment and remittance will be sent. Complete the NPI form below for medical facilities, groups, clinics, and sole practitioners and durable medical equipment suppliers. 

Return completed form(s) to:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373

  • Created: Jan 8, 2018
  • Modified: Jan 8, 2018
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Provider Claims Fax Cover Sheet

You can use this provider fax cover sheet when submitting the following: 

  • Corrected claim requests
  • Referral information from the primary care manager
  • Duplicate claim review documentation
  • Claim check review documentation
  • Other miscellaneous requests

The appropriate fax number is listed on the cover sheet. 

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
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Provider Refund Form - Multiple Claims

Complete this form and mail with the personal refund check and supporting documentation to: 

PGBA, LLC
TRICARE West Region Finance
PO Box 202111
Florence, SC 29502-2111

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
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Provider Refund Form - Multiple Claims

Complete this form and mail with the personal refund check and supporting documentation to: 

PGBA, LLC
TRICARE West Region Finance
PO Box 202111
Florence, SC 29502-2111

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
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Reimbursement of Capital and Direct Medical Education Costs

Return the required information to: 

TRICARE CAPDME West Region
PO Box 202113
Florence, SC 29502-2113

  • Created: Dec 30, 2017
  • Modified: Oct 25, 2017
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Taxpayer Identification Number Request (W-9)

Providers should complete this form when solo practitioners change their legal name, providers change their legal business name or providers change their pay to address. Return the completed form to HNFS.

Mail: 

TRICARE West Finance
PO Box 202111
Florence, SC 29502-2111

Fax:

Network Providers: 1-844-836-5818
Non-Network Providers: 1-844-730-1373

  • Created: Jan 3, 2019
  • Modified: Jan 3, 2019
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Statement of Personal Injury – Possible Third Party Liability

Claims submitted with diagnosis codes 800–999 for professional services exceeding $500 and inpatient services often indicate an accidental injury or illness. When filing these claims, the provider needs to have the beneficiary complete the Possible Third Party Liability form.

Fax form to: 1-844-869-2813

 

Tip: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." 

  • Created: Jan 18, 2019
  • Modified: Jan 18, 2019
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Non-Network UB-04 'Signature on File' for TRICARE Claims

Return the completed form to:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
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