SECTION 5: Provider Claims Information - TRICARE Overseas

TRICARE overseas ProgramProvider ManualPart 3: This section can be left blank, as long as an Itemized Invoice is submittedThis information should be on the Itemized Invoice which must be submitted with the Claim Form.Part 4: Sponsor’s Details and Authorization NumberIf the patient has OHI, enter the nameof the insured party using the formatLast Name, First Name, Middle Initialand the policy number.Always indicate ‘Y’ for ‘Yes’here. This ensures thatpayment goes to the Provider.If the patient has OHI, it will be the primary payer for the claim.After the OHI has processed the claim, indicate here howmuch they have paid. Also include any payments the patienthas made towards the claim. If TRICARE is the patient’s onlyhealth insurance plan, leave this field blank.SECTIoN 5Provider Claims InformationPlease enter the appropriateAuthorization Number. This canbe found on the top right cornerof the Authorization Form.Enter the sponsor’s name using the format Last Name, FirstName, Middle Initial and the sponsor’s ID number (SSN or thefirst 9 digits of the DOD Benefits Number). This information willappear on the patient’s Military ID Card.67