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Temporary Hold on Claims with 2026 Dates of Service

Claims with dates of service beginning January 1, 2026, will be temporarily held to allow validation of updated 2026 reimbursement rates and beneficiary fee changes. This proactive hold is expected to last no more than 30 days, after which claims will be released for processing.

Claims & Documents Reference Guide

The purpose of this page is to help you determine the best place to send your TRICARE West Region claims forms and documentation. All provider forms are available in Availity. Whenever possible, please submit your forms and documentation in Availity. This is the fastest way to submit documentation and provide care for your patients.

provider using computer

Form Name	When to Use	Mailing Address	Fax
HCFA 1500 or UB04: Claim or Corrected Claim Submissions	Original Claim or Corrected Claim Network Providers Must Submit Electronically (AK is exempt from requirement)	TRICARE West-Claims P.O. Box 202160 Florence, SC 29502	877-989-0070
Supporting Documentation - Medical Records	Denied claim that requires supporting medical documentation	TRICARE West-Med Recs P.O. Box 202165 Florence, SC 29502	877-989-0047
EFT & ERA Enrollment Form	Set up electronic deposits and provider remittance advices	T-5 TRICARE West Region P.O. Box 202161 Florence, SC 29502 TRT5EFT@PGBA.com	877-989-0032
Certificate of Medical Necessity	Denied or in-process durable medical equipment claim	TRICARE West-DME P.O. Box 202167 Florence, SC 29502	877-989-0030
Supporting Documentation - Prescription For Durable Medical Equipment Claim	Denied or in-process durable medical equipment claim requiring a prescription	TRICARE West-DME P.O. Box 202167 Florence, SC 29502	877-989-0030
Supporting Documentation - Breast Feeding Supplies	Denied or in-process claim for breast feeding supplies	TRICARE West-DME P.O. Box 202167 Florence, SC 29502	877-989-0030
Claims Reconsideration Form	Claim billed correctly but disagree with outcome Not for formal appeals or submitting supporting documentation	TRICARE West Provider Claims Correspondence P.O. Box 2748 Virginia Beach, VA 23450	866-852-1969
Timely Filing Waiver	Retroactive eligibility or authorization after filing deadline Patient mentally incompetent and no legal guardian appointed Claim was submitted and assigned claim number before filing deadline OHI EOB received within filing deadline and claim submitted within 90 days of OHI decision	TRICARE West Provider Claims Correspondence P.O. Box 2748 Virginia Beach, VA 23450	866-852-1969
Claims Formal Appeal (No form required - submit in writing with signature and supporting documentation)	Denied claim due to TRICARE policy limitations Claim denied as not medically necessary Denied services are not covered by TRICARE Claim processed as POS only when the reason for dispute is that the service was for emergency care (Any other reasons/requests for review should be submitted as a reconsideration)	TRICARE West Claims Appeals P.O. Box 2777 Virginia Beach, VA 23450	866-670-4330
Recoupment Request Form	Submit a refund due to overpayment	TRICARE West-Finance P.O.Box 202162 Florence, SC 29502	N/A
W-9 (Government Form)	Change a tax record through W-9	TRICARE West-1099 P.O. Box 202173 Florence, SC 29502	877-989-0333
Third Party Liability (TPL) Supporting Documentation - Medical Records	Denied claim due to lack of TPL form and services indicated in medical records as not related to TPL	TRICARE West-TPL P.O. Box 202170 Florence, SC 29502	877-989-0262

The following are beneficiary forms your patients may ask about. Please point them to the TRICARE West Region Beneficiary Portal to access these forms.

Beneficiary Form	When to Use	Mailing Address	Fax
Other Health Insurance (OHI) Questionnaire	Beneficiary needs to update insurance records	TRICARE West-OHI P.O. Box 202168 Florence, SC 29502	877-989-0262
Beneficiary Claim Form (DD2642)	Reimbursement request for care while traveling or from nonparticipating provider	TRICARE West-Claims P.O. Box 202160 Florence, SC 29502	877-989-0070
Beneficiary Correspondence	Beneficiary was balance billed in error or sent to collections Beneficiary wants to appeal a claim determination	TRICARE West Beneficiary Correspondence P.O. Box 2130 Virginia Beach, VA 23450	866-852-1994