SECTION 5: Provider Claims Information - TRICARE Overseas

TRICARE overseas ProgramProvider ManualPart 4: Provider’s DetailsThe ‘Federal Tax ID Number’ is theProvider’s TRICARE ID Number(or TEPRV). Please enter this here.Always indicate ‘Yes’ here. Thisensures that payment goes to theProvider.If the patient has OHI, it will be the primary payerfor the claim. After the OHI has processed theclaim, indicate here how much they have paid.Also include any payments the patient has madetowards the claim. If TRICARE is the patient’s onlyhealth insurance plan, leave this field blank.This must be signed anddated by the Provider.This does notnecessarily have to bethe attending physician,but can be signed by anauthorized person.Note: The Provider‘Signature on File’procedure can beused here.Please enter thepatient’s accountnumber. This isgenerated by theProvider andshould not belonger than 18digits long.Please enterthe Provider’sname and fullphysicaladdress.Fields highlighted in greencan be left blankPlease enter theProvider’s full billingaddress if different tothe physical address.SECTIoN 5Provider Claims Information63