Dd Form 2642 - Tricare Dod/champus Medical Claim - Patient'S Request For Medical Payment

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What is Dd Form 2642 and Instructions on filling it out

- PATIENT'S COPY -

OMB No. 0720-0006

TRICARE DoD/CHAMPUS MEDICAL CLAIM

OMB approval expires

PATIENT'S REQUEST FOR MEDICAL PAYMENT

August 31, 2018

The public reporting burden for this collection of information, 0720-0005, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this

collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-

collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it

does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE

APPROPRIATE CLAIMS PROCESSOR. IF YOU DO NOT KNOW WHO YOUR CLAIMS PROCESSOR IS, CONTACT A BENEFICIARY

COUNSELING AND ASSISTANCE COORDINATOR (BCAC) OR TRICARE MANAGEMENT ACTIVITY (303) 676-3400.

PRIVACY ACT STATEMENT

AUTHORITY: 44 U.S.C. 3101; 10 U.S.C. 1079 and 1086; 38 U.S.C. 1781; E.O. 9397.

PRINCIPAL PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility

and determination that the services/supplies received are authorized by law.

ROUTINE USE(S): Information from claims and related documents may be given to the Department of Health and Human Services and/or the

Department of Homeland Security consistent with their statutory administrative responsibilities under CHAMPUS; to the Department of Justice for

representation of the Secretary of Defense in civil actions; to the Internal Revenue Service and private collection agencies in connection with

recoupment claims; and to Congressional offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate

disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on

matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity,

third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS.

DISCLOSURE: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim.

IMPORTANT - READ CAREFULLY

Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, fictitious or fraudulent statement

or claim in any matter within the jurisdiction of any department or agency of the United States. Examples of fraud include situations in which ineligible

persons knowingly use an unauthorized Identification Card in filing of a CHAMPUS claim; or where providers submit claims for treatment, supplies or

equipment not rendered to, or used for TRICARE DoD/CHAMPUS beneficiaries; or where a participating provider bills the beneficiary/patient (or

sponsor) for amounts over the CHAMPUS-determined allowable charge; or where a beneficiary/patient (or sponsor) fails to disclose other medical

benefits or health insurance coverage.

INCOMPLETE CLAIM FORMS WILL DELAY PAYMENT

NONAVAILABILITY STATEMENT REQUIREMENTS:

If the patient resides within the catchment area of a Military Treatment Facility (MTF)

(generally within a 40-mile radius of the MTF), you will need to obtain a Nonavailability Statement (NAS) from the MTF for a hospital admission for

mental health that is not a bona fide emergency. Without a necessary NAS your claim will be denied.

* * * * * *

ITEMIZED BILL: Ask your provider to complete the HCFA Form 1500 for you. If the provider refuses, complete this form and attach an itemized bill

which must be on the provider's billing letterhead. The bill must contain the following information:

1. Doctor's or provider's name/address (the one that actually provided your care). If there is more than one provider on the bill, circle

his/her name;

2. Date of each service;

3. Place of each service;

4. Description of each surgical or medical service or supply furnished;

5. Charge for each service;

6. The diagnosis should be included on the bill. If not, make sure that you've completed block 8a on the form.

DRUGS: Prescription claims require the name of the patient; the name, strength, date filled, days supply, quantity dispensed, and price of each

drug; NDC for each drug if available; the prescription number of each drug; the name and address of the pharmacy; and the name and address

of the prescribing physician. Billing statements showing only total charges, or canceled checks, or cash register and similar type receipts are not

acceptable as itemized statements, unless the receipt provides detailed information required above.

* * * * * *

TIMELY FILING REQUIREMENTS: All claims must be filed no later than one year after the services are provided; or for inpatient care, one year from

the date of discharge. If a claim is returned for additional information, it must be resubmitted by the filing deadiline, or within 90 days of the notice --

whichever date is later.

* * * * * *

WHERE TO OBTAIN ADDITIONAL FORMS: You may obtain additional claim forms from your claims processor, the TRICARE Service Center at the

nearest military treatment facility or TRICARE Management Activity, 16401 E. Centretech Pkwy., Aurora, CO 80011-9066.

* * * REMINDER * * *

Before submitting your claim to the claims processor be sure that you have:

1. Completed all 12 blocks on the form. If not signed, the claim will be returned.

2. Verified that the sponsor's SSN is correct.

3. Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.

4. Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.

5. Obtained a Nonavailability Statement if required (see information above).

6. Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity" if accident