TRICARE West Region Provider Forms

Welcome TRICARE West Region providers! Here you will find a variety of forms you may need to manage your patients’ health care. You can download and print these forms.

Claims

• Claims Reconsideration
• Certificate of Medical Necessity
• EDI Gateway Technical Communications User's Manual
• EDI Provider Trading Partner Agreement
• Electronic Funds Transfer (EFT) & Electronic Remittance Advice (ERA) Enrollment Package
• Recoupment Request
• Timely Filing Waiver
• Request for Non-covered Services
• Capital and Direct Medical Education Costs Reimbursement

Clinical Care

• TRICARE Clinical Care Support Program Referral Form
• ECHO Home Health Attestation Form

Customer Service

• TRICARE West Region Potential Quality Issue Form

Non-Network Provider Application

• TRICARE Non-Network Autism Care Demonstration (ACD) (BCBA, BCBA-D and LBA) Individual Application
• Non-network TRICARE Provider File Group Application

Referrals and Authorizations

Online referrals/auths is the fastest way to process care requests for your TRICARE patients. Read the referral/authorization guidelines to learn more. If you have issues submitting your referral or authorization using the online referral management system, please use the Alternative Referral and Authorization Form available on Availity. For more information, view the Alternative Referral and Authorization Form Quick Reference Guide.

Already submitted via fax? Consider resubmitting online for faster response times.

• TRICARE West Region Referral/Authorization Form
  NOTE: Use of this fax form should be limited. Please ensure you have read the West Region referral/authorization guidelines before submitting.

Participation Agreements

• Autism Care Demonstration Program
• Birthing Center / Maternity Care Services
• Certified Labor Doulas
• Hospice Program
• Intensive Outpatient
• Marriage and Family Therapist
• Opioid Treatment Program
• Residential Treatment Center
• Substance Use Disorder Residential Facility