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Network Provider Forms

Network Provider Information Form

In addition to the CAQH credentialing application, TRICARE network provider applicants (does not apply to non-network providers) must also submit a supplemental Provider Information Form or PIF. This supplemental application requests information unique to TRICARE that is not addressed within the CAQH application.

Note: Do not use this form to update demographic information. This form is for credentialing purposes only. Please review our FAQ on how to update demographic information

  • Provider groups: Provider groups with 20 or more individual providers can complete the TRICARE Provider Group Roster rather than a PIF for each provider.  

We require 30 days to process new PIFs. Please allow for this time frame before contacting us regarding your application status. Keep in mind, the full credentialing process takes, on average, 60–90 days from the date we receive a completed application. You can check status using our Check Credentialing Status tool.

You may mail or fax your completed PIF.

If faxing, use the fax cover sheet included in the form as the first page of your fax. Applications that do not have this cover sheet as the first page of the fax will not be processed.

Mailing Address:
Health Net Federal Services, LLC/TRICARE
Attn: Provider Network Management
PO Box 9410
Virginia Beach, VA 23450-9410

Fax:
1-844-224-0381

  • Created: Sep 10, 2019
  • Modified: Jul 15, 2019
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Network Applied Behavior Analysis (ABA) Provider Participation Packet

ABA providers interested in joining the Health Net Federal Services, LLC (HNFS) network for the TRICARE West Region contract must complete this packet and submit it to HNFS. 

  • Note: This packet is for applied behavior analysis (ABA) providers only. 

Groups of more than 20 providers: Please email a group roster to hnfsT2017ProvRel@Healthnet.com rather than completing a Provider Information Form for each provider. 

Fax: 1-844-836-5818

Mailing Address:
Health Net Federal Services, LLC/TRICARE
Attn: Provider Network Management
PO Box 9410
Virginia Beach, VA 23450-9410

  • Created: Sep 10, 2019
  • Modified: Jul 24, 2019
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Network Provider Participation Packet

Professional providers interested in joining the Health Net Federal Services, LLC (HNFS) network for the TRICARE West Region contract must complete this packet and submit it to HNFS. The packet consists of a Provider Participation Agreement, Provider Information Form and IRS Form W-9. All professional providers associated with your agreement must be credentialed by HNFS.

  • Applied behavior analysis (ABA) providers: Do not complete this packet. Instead complete the ABA-specific provider participation packet.
  • Facilities and ancillary providers: Do not complete this packet. Please send an email to hnfsT2017ProvRel@healthnet.com to request a contract.

Groups of more than 20 providers: Please email a roster to hnfsT2017ProvRel@Healthnet.com rather than completing a Provider Information Form for each provider. 

Fax: 1-844-836-5818

Mailing Address: 
Health Net Federal Services, LLC/TRICARE
Attn: Provider Network Management
PO Box 9410
Virginia Beach, VA 23450-9410

  • Created: Aug 19, 2015
  • Modified: Jul 24, 2019
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TRICARE Provider Group Roster

Rather than submitting an individual Provider Information Form, Health Net Federal Services, LLC (HNFS) offers a TRICARE Provider Group Roster* for:

  • Provider groups joining the HNFS West Region network who have 20 or more individual providers they wish to credential
  • Existing network providers who would like to make changes to demographic or credentialing information to 20 or more individual providers
  • Groups who have a delegated credentialing agreement with HNFS (regardless of the number of individual providers)
  • Behavior technicians (BTs) who need to submit provider certification information to HNFS (regardless of the number of BTs)

Be sure to complete all columns in the spreadsheet and email it to hnfsT2017ProvRel@Healthnet.com. 

  • Do not include providers located in the East Region states. 
  • Exceptions for ABA providers: BTs should indicate ‘RBT’ in the ‘Degree’ field. If not licensed, indicate the type of certification. The ‘Medicare Number’ field can be left blank.

Please allow up to 90 days for processing (21 days for loading certified BTs). 

  • You can check status using our Check Credentialing Status tool; however, you will need to enter in individual NPIs when using this tool.
  • While BTs are certified and not credentialed, they can also use the Check Credentialing Status tool to check certification status.   

HNFS will issue a determination letter to the credentialing point of contact for each practitioner once the credentialing process has completed.

*In order to access the roster, click the link above and save the Excel file locally on your computer. After completing all of the fields, save the file again and submit a copy to the email address above. 

  • Created: Aug 29, 2019
  • Modified: Aug 29, 2019
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