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Military Hospital or Clinic Use Only

Potential Quality Issue (PQI) Referral Form

For TRICARE West Region military hospital and clinic use only. Used to report potential quality issues to Health Net Federal Services, LLC and TRICARE Regional Office-West.

  • Created: Jan 11, 2018
  • Modified: Dec 29, 2017
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Request to Reverse Payment Determination for Service Member Claims

The military hospital or clinic designees authorized to provide Service member claim payment direction may, by use of this form, request to overturn previous payment determination(s), resulting in either a payment or recoupment of previously processed Service member claims in the West Region. Please fax this form to 1-844-730-1364 for processing.

  • Created: Dec 31, 2017
  • Modified: Dec 29, 2017
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