TRICARE DoD/CHAMPUS Medical Claim - Patient's Request for Medical Payment

Submit the completed TRICARE/CHAMPUS Medical Claim form to the appropriate claims processor. Attach all necessary documents, such as itemized bills, Explanation of Benefits, and Nonavailability Statements if required. Physical addresses for submission are available through the TRICARE Service Center or TRICARE Management Activity at 16401 E. Centretech Pkwy., Aurora, CO 80011-9066. For further assistance, contact a Beneficiary Counseling and Assistance Coordinator (BCAC) or TRICARE Management Activity at (303) 676-3400. Ensure all fields are completed and all documents are attached before submitting. Making a copy of the claim and attachments for your records is advisable.

Submit your TRICARE/CHAMPUS claim form within one year of receiving services, or within one year of discharge for inpatient care. If any additional information is requested, resubmit within 90 days of notice.

The TRICARE/CHAMPUS Medical Claim form is designed for patients seeking reimbursement for medical expenses under the TRICARE DoD/CHAMPUS program. This form requires detailed patient information, descriptions of medical services, and appropriate documentation to verify and process the claim. By accurately completing and submitting this form, eligible beneficiaries can receive timely payments for covered medical services. This form plays a crucial role in ensuring that military personnel and their families are reimbursed for medical expenses incurred at civilian healthcare facilities. It also helps in documenting and evaluating the eligibility of medical services provided to TRICARE beneficiaries. Proper use of this form ensures that claims are processed efficiently, reducing the time taken for reimbursement. The purpose of this form is to streamline the process of medical claims for TRICARE beneficiaries, ensuring they receive due compensation for their medical expenses. It is vital for patients and their families to understand and accurately fill out this form to avoid any delays in processing their claims.

• 1. Patient's Name: The patient's full name, including last, first, and middle initial.
• 2. Patient's Telephone Number: Contact numbers for the patient, including daytime and evening phone numbers with area code.
• 3. Patient's Address: The full address of the patient's residence at the time of service, including street, city, state, and ZIP code.
• 4. Patient's Relationship to Sponsor: Indicator of the patient's relationship to the sponsor, such as self, spouse, or child.
• 5. Patient's Date of Birth: The patient's date of birth in YYYYMMDD format.
• 6. Patient's Sex: The patient's gender, marked as male or female.
• 7. Patient's Condition: Description of the condition or injury for which treatment was received, including how it happened.
• 8. Inpatient/Outpatient/Pharmacy: Indicator of where the care was given: inpatient, outpatient, pharmacy, or day surgery.
• 9. Sponsor's/Former Spouse's Name: The full name of the sponsor or former spouse, as it appears on the military ID card.
• 10. Sponsor's/Former Spouse's Social Security Number: The Social Security Number of the sponsor or former spouse.
• 11. Other Health Insurance Coverage: Information about additional health insurance coverage, including policy details and coverage types.
• 12. Signature of Patient or Authorized Person: Signature of the patient or an authorized person certifying the correctness of the claim and authorizing the release of information.
• 13. Payment in Local Currency: For overseas claims, an indicator of whether payment is requested in local currency.

Failure to submit the TRICARE/CHAMPUS Medical Claim form may result in delayed or denied reimbursement for medical expenses.

• Delayed Payment: Incomplete or missing information can cause delays in processing and payment of claims.
• Claim Denial: Failure to provide necessary documents or information may result in the denial of the claim.
• Legal Consequences: Submitting false information may lead to criminal penalties under federal law.

• 1. Medical Services: When seeking payment for medical treatment received from civilian providers.
• 2. Prescription Claims: For claiming costs associated with prescription medications.
• 3. Hospital Admissions: For inpatient care, including hospital stays and surgeries.
• 4. Mental Health Services: When claiming expenses for mental health treatment received outside military facilities.
• 5. Accident or Work-Related Injuries: To report and seek reimbursement for injuries related to accidents or work.