Provider forms

Claims Behavioral health Pharmacy Misc

Claim forms

Certificate of Medical Necessity (CMN)
Proactive recoupment form
Claim form (DD 2642)
Reconsideration coversheet/tipsheet
Noncovered services waiver form

Behavioral health forms 

Behavioral health continued stay request
Progress notes for Applied Behavior Analysis (ABA)
Behavioral health discharge form
Recoupment tip sheet for ABA providers
Behavioral health initial request
Referral for Applied Behavior Analysis
Brexanolene (ZULRESSO) therapy treatment request
Request for Applied Behavior Analysis (Reassessment)
Clinical diagnosis: DSM-5 diagnostic checklist
Residential Treatment Center (RTC) concurrent review
Electroconvulsive Therapy (ECT)
Residential Treatment Center (RTC) initial review
Initial request for Applied Behavior Analysis
Spravato therapy release form
Outpatient/Ambulatory Opiate and Substance Use Disorder (SUD)
Transcranial Magnetic Stimulation (TMS)

Specialty pharmacy forms

Accredo prescription enrollment form
US Bioservices patient enrollment form
Accredo drug therapy search
Accredo prescription enrollment form
Medex BioCare general injectable prescription and enrollment form

Miscellaneous forms

Care management referral form
PRO agreement

To participate in the care of TRICARE beneficiaries, facilities must establish a Peer Review Organization (PRO) agreement with Humana Military in accordance with 32 CFR 199.15(g). Learn more

Change TIN form
Provider roster update: Delegated
Concurrent hospice and curative care monthly service activity log
Provider roster update: Non-delegated
Continuous glucose monitor attestation form
Provider Information Update Request form
Important message from TRICARE
Reimbursement of capital and direct medical education costs
Laboratory Developed Tests (LDT) attestation form
Request for Banked Donor Milk (BDM)
Medical record request/tipsheet
Standard Acquisition Charges (SAC) for organ acquisition
Patient referral authorization

Providers should submit referrals and authorizations through provider self-service. Faxed forms will only be accepted if the provider is unable to submit them electronically.

FAQs, tipsheets and more

FAQs Tipsheets Presentations

Frequently Asked Questions (FAQ)

Appeal submission process
Provider eligibility
Claim status policy
Provider roster upload self-service
Clear and Legible Reports (CLR)
Reconsideration
Freestanding Emergency Room (ER)
Recoupment summary search via provider self-service

Tipsheets

Behavioral healthcare services
TRICARE covered clinical preventive services
Eligibility and Benefit Inquiry (270) and Eligibility and Benefit Response (271)
TRICARE DME guidelines
Pediatric PCM information
TRICARE Prime and Select comparison
Proper submission paths for TRICARE claims and claims-related documents
TRICARE Referrals and prior authorizations
Provider claims submission
TRICARE Right of First Refusal process
Provider resources
Using provider self-service
Recoupment tip sheet for Applied Behavior Analysis (ABA) providers

Presentations

Provider orientation
Approach to code editing
Care Considerations and provider feedback