In lieu of separate clinical documentation, complete the Banked Donor Milk Coverage Criteria Attestation and submit it, along with the prescription, with your initial claim online or by mail or fax, or as indicated on the additional information request within 14 days of the letter to:
TRICARE West Claims
PO Box 202112
Florence, SC 29502-2112
Fax: 1-844-869-2504
- Created: Aug 1, 2022
- Modified: Sep 16, 2019
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In lieu of creating a separate prescription form, complete the Breast Pump and Supplies Prescription form and submit it with your initial claim online or by mail or fax.
TRICARE West Claims
PO Box 202112
Florence, SC 29502-2112
Fax: 1-844-869-2504
- Created: Aug 1, 2022
- Modified: Sep 16, 2019
- View »
Use this form to register for, update or terminate an electronic funds transfer (EFT) for the TRICARE West Region. Additional steps may be required. Learn more on our EFT/ERA page.
Fax the completed EFT Authorization Agreement to 1-844-787-9889.
- Created: Aug 1, 2022
- Modified: Mar 31, 2020
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Use this form to enroll in electronic remittance advice (ERA) for the TRICARE West Region.
- Created: Aug 1, 2022
- Modified: Feb 15, 2018
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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: Aug 1, 2022
- Modified: Sep 30, 2019
- View »
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: Aug 1, 2022
- Modified: Sep 30, 2019
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Use this form to request reimbursement of the TRICARE hospice cap amount for services within the cap period ending Oct. 31, 2024.
Return completed form to:
TRICARE West Region
Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Sep 13, 2024
- Modified: Sep 13, 2024
- View »
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: Aug 1, 2022
- Modified: Jan 8, 2018
- View »
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: Aug 1, 2022
- Modified: Jun 7, 2019
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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: Aug 1, 2022
- Modified: Dec 30, 2017
- View »
Return the required information to:
TRICARE CAPDME West Region
PO Box 202113
Florence, SC 29502-2113
- Created: Aug 1, 2022
- Modified: Oct 25, 2017
- View »
Claims submitted with ICD-10-CM S and T diagnosis codes or ICD-9-CM 800–999 diagnosis codes 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: Aug 1, 2022
- Modified: Jul 5, 2022
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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: Aug 1, 2022
- Modified: Jan 3, 2019
- View »
Return the completed form to:
TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Aug 1, 2022
- Modified: Sep 30, 2019
- View »
