Fillable North Provider Refund Form - Single Claim (Tricare North Region) printable pdf download

North Provider Refund Form - Single Claim (Tricare North Region)

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North Provider Refund Form – Single Claim

Instructions

Please complete this form and mail with the personal refund check and supporting documentation. If you are

using your own form or spreadsheet, please ensure it contains the information below. An electronic copy of this

form is available in the Forms section at For refunds involving multiple claims, please use

Provider Refund Form – Multiple Claims, which can also be found in the Forms section at

Provider Information:

Provider Name:

Provider Tax Identification/National Provider Identification Number:

Refund Information:

Refund Amount:

Select the code that best describes the purpose of the refund.

200- Other Health Insurance (Beneficiary has other health insurance)

201- Third Party Liability (Automobile Accident, Home Accident, Workman’s Compensation, etc.)

202- Paid Wrong Provider (Payment sent to wrong address or incorrect TIN)

204- Duplicate Payment (TRICARE Paid Twice)

208- Provider Billing Error (Claim submitted in error, with incorrect information and/or returned supplies)

281- System Pricing Error (TRICARE paid at a rate greater than contracted)

Other- (Complete Comments Section)

Patient Information:

(Complete all available patient information related to the refund.)

Patient’s Name:

Sponsor Number:

Claim Number:

Procedure/Revenue Code(s):

Date(s) of Service:

Comments:

(List any additional information not provided above.)

PGBA, LLC.

TRICARE Refunds

Attn: TRICARE North Region

PO Box 870153

Surfside Beach, SC 29587-9753

North Provider Refund Form - Single Claim (Tricare North Region)

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