Provider Fax Cover Sheet Sample printable pdf download

Provider Fax Cover Sheet

To:

TRICARE West Region

Fax: _____________________

From: ___________________________

Fax: _____________________

Number of pages (including cover sheet):

_______________

Patient Name:

___________________________________________________________

Date(s) of Service:

___________________________________________________________

TRICARE Claim Number:

___________________________________________________________

Tax Identification Number:

___________________________________________________________

Reason for Correspondence

__ Corrected Claim- Corrections to be made: _________________________________________________

____________________________________________________________________

__ Referral Information from PCM (Claims processing with Point of Service Option)

__ Duplicate Review – Supporting medical documentation for services denied as a Duplicate

__ Claim Check Review – Supporting medical documentation for services denied per Claim check

__ Other: _____________________________________________________________________________

____________________________________________________________________________

Please use the appropriate secure FAX number from the list below:

Routine Correspondence: 855-831-7048

Appeals: 877-584-6628

IEP/Physicians Orders: 855-831-7041

Medical Documentation: 855-831-7041

Priority Correspondence: 855-831-7045

Third Party Liability Forms: 855-831-7045

Authorizations/Referrals: 877-890-9309

Durable Medical Equipment: 855-831-7040

Other Health Insurance Updates: 855-708-4772

Authorization to Disclose Information: 855-831-7047

Save time as a registered member of

to manage your TRICARE business online, anytime, day or night! You

can view claim status, authorization/referral status, PCM name, Eligibility, cost-share, copay and deductible information, and update

your other health insurance (OHI). You can send a confidential, secure inquiry about a specific claim through AskUs and receive a

prompt response in your personal, secure myTRICARE mailbox.

Provider Fax Cover Sheet Sample