Electronic Submission Of Tricare Overseas Claims Form printable pdf download

Electronic Submission of TRICARE Overseas Claims Form

An organization that has several providers can execute a single Form on behalf of the group. Only one authorizing

individual is needed to sign this Form for the Clinic / Group. However a complete list of all locations and providers for which

you will be billing will need to be completed on submission of this form (these may be listed on Appendix 1 for Individual

Providers and Appendix 2 for Institutional Providers if submitted together with the Mutual Co-operation Protocol).

Physician Clinic Name:

_______________

TRICARE Assigned Provider ID:

_________________

NPI Number of Provider (if applicable – US Territories only):

_______________

Claim Type (select one or both):

Institutional Provider (Hospital or Ambulatory Day Surgery)

Individual Provider or Group Practice

Please submit a completed Appendix 1 for Individual Provider or Group Practice and / or Appendix 2 for

Institutional Provider

Please indicate your EDI submission option:

Online claim submission at

Vendor supplied EDI software program. Name of Vendor_________________________________

Electronic claim submission using PC-ACE software provided by WPS

Clearinghouse or Billing Service. Name of Billing Service /Clearinghouse____________________

In submitting electronic transactions using option 2, 3 or 4 above, the Healthcare Provider will follow the

specifications required by the most current version named under the HIPAA Transactions and Code Sets rules.

For claim transactions, the Healthcare Provider agrees that each and every claim submitted via electronic

media, for all legal and other purposes, will be considered to be signed by the Healthcare Provider or the

Healthcare Provider's authorized representative.

For claim transactions, the Healthcare Provider agrees to maintain a patient signature file. The Healthcare

Provider understands International SOS may validate through file audits those claims submitted via electronic

media which are included in any quality control or sampling method requested by International SOS. The

Healthcare Provider understands that if no signed authorization is on file, an authorization must be obtained by the

Healthcare Provider from the patient prior to electronic submission to International SOS.

The Healthcare Provider acknowledges that International SOS shall have no obligation with respect to the

content of the information in claims to verify, check or otherwise inspect the information supplied by the Healthcare

Provider. The Healthcare Provider further acknowledges that International SOS is solely responsible for

determining the completeness, accuracy and validity of the information and claims and that source documents for

claims data are the responsibility of the Healthcare Provider.

Electronic Submission Of Tricare Overseas Claims Form