Claims & Documents Reference Guide
The purpose of this page is to help you determine the best place to send your TRICARE West Region claims forms and documentation. All provider forms are available in the provider portal, Availity. Whenever possible, please submit your forms and documentation in the provider portal, Availity. This is the fastest way to submit documentation and provide care for your patients.
| Form Name | When to Use | Mailing Address | Fax |
|---|---|---|---|
| HCFA 1500 or UB04: Claim or Corrected Claim Submissions |
|
TRICARE West-Claims P.O. Box 202160 Florence, SC 29502 |
877-989-0070 |
| Supporting Documentation - Medical Records |
|
TRICARE West-Med Recs P.O. Box 202165 Florence, SC 29502 |
877-989-0047 |
| EFT & ERA Enrollment Form | Set up electronic deposits and provider remittance advices | T-5 TRICARE West Region P.O. Box 202161 Florence, SC 29502 TRT5EFT@PGBA.com |
877-989-0032 |
| Certificate of Medical Necessity | Denied or in-process durable medical equipment claim | TRICARE West-DME P.O. Box 202167 Florence, SC 29502 |
877-989-0030 |
| Supporting Documentation - Prescription For Durable Medical Equipment Claim | Denied or in-process durable medical equipment claim requiring a prescription | TRICARE West-DME P.O. Box 202167 Florence, SC 29502 |
877-989-0030 |
| Supporting Documentation - Breast Feeding Supplies | Denied or in-process claim for breast feeding supplies | TRICARE West-DME P.O. Box 202167 Florence, SC 29502 |
877-989-0030 |
| Claims Reconsideration Form |
|
TRICARE West Provider Claims Correspondence P.O. Box 2748 Virginia Beach, VA 23450 |
866-852-1969 |
| Timely Filing Waiver |
|
TRICARE West Provider Claims Correspondence P.O. Box 2748 Virginia Beach, VA 23450 |
866-852-1969 |
| Claims Formal Appeal (No form required - submit in writing with signature and supporting documentation) |
|
TRICARE West Claims Appeals P.O. Box 2777 Virginia Beach, VA 23450 |
866-670-4330 |
| Recoupment Request Form | Submit a refund due to overpayment | TRICARE West-Finance P.O.Box 202162 Florence, SC 29502 |
N/A |
| W-9 (Government Form) | Change a tax record through W-9 | TRICARE West-1099 P.O. Box 202173 Florence, SC 29502 |
877-989-0333 |
| Third Party Liability (TPL) Supporting Documentation - Medical Records | Denied claim due to lack of TPL form and services indicated in medical records as not related to TPL | TRICARE West-TPL P.O. Box 202170 Florence, SC 29502 |
877-989-0262 |
Finding Provider Forms in the Provider Portal, Availity
- Log in to the provider portal, Availity.
- Go to TRIWEST - TRICARE Payer Space.
- Scroll down and select All Provider Forms under the Applications tab.
The following are beneficiary forms your patients may ask about. Please point them to the TRICARE West Region Beneficiary Portal to access these forms.
| Beneficiary Form | When to Use | Mailing Address | Fax |
|---|---|---|---|
| Other Health Insurance (OHI) Questionnaire | Beneficiary needs to update insurance records | TRICARE West-OHI P.O. Box 202168 Florence, SC 29502 |
877-989-0262 |
| Beneficiary Claim Form (DD2642) | Reimbursement request for care while traveling or from nonparticipating provider | TRICARE West-Claims P.O. Box 202160 Florence, SC 29502 |
877-989-0070 |
| Beneficiary Correspondence |
|
TRICARE West Beneficiary Correspondence P.O. Box 2130 Virginia Beach, VA 23450 |
866-852-1994 |