Triwest provider claims timely submission reconsideration form

Q: What is WPS TriWest?

WPS Military and Veterans Health (WPS MVH) is TriWests claims processor for the Department of Veterans Affairs (VA) Veterans Choice Program (VCP) and the Patient-Centered Community Care (PC3) program. Until recently, WPS MVH had different Payer IDs for both the VCP and PC3 programs.

Table of Contents Show

Do you need an enrollment form?
Do you need a pharmacy form?
Do you need a dental form?
Are you a remotely located Active Duty or Reserve Component service member?
Do you need to file a claim?
Are you looking for another form?
Region-Specific Forms
How do I submit a claim to TriWest?
Does TriWest have a provider portal?
What is the payer ID for TriWest?
What is WPS TriWest?

Forms & Claims

Find the form you need or information about filing a claim.

Claims may be delayed or denied because the claim form wasn't filled out correctly or all the information wasn't provided. Here are some tips to help you file your claims correctly:

Keep DEERS Updated	Incorrect information in DEERS could cause your TRICARE claim to be denied. Update DEERS now!
Use the Right Form	File medical claims on a Patient's Request for Medical Payment (DD Form 2642).
Fill in all 12 Blocks	Include the sponsor's Social Security Number or Department of Defense Benefits Number, your home address and phone number, as well as any other pertinent information needed.
Use the Right Diagnosis Code	Your provider should give you a diagnosis code for all services he or she provided. Include that code with the description in Box 8a.
Sign the Claim Form	Claims submitted without a signature will be denied payment.
Notify TRICARE if there's a Third Party Involved	If you were hurt in an accident and someone else may bear responsibility, you have to let TRICARE know by submitting a Statement of Personal Injury-Possible Third Party Liability (DD Form 2527) along with your medical claim form.
File Claims with OHI First	TRICARE pays second to most other health insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance." (OHI) programs. When you receive payment from your OHI, you can then file a claim with TRICARE. Include a copy of your explanation of benefits from your OHI with your TRICARE claim.
Make Copies	Keep copies of everything you submit to the claims processor.
Use the Right Claims Address	Send your claim forms to the correct address to avoid delays. View claims addresses.
File Claims on Time	Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge or three years if overseas, but you are encouraged to send your claim form to TRICARE as soon as possible after you receive care.
Submit Each Claim Separately	Filing multiple claims together could cause confusion.

Last Updated 8/16/2022

You can access commonly used forms below or browse the menu on the left for more information.

Do you need an enrollment form?

Enroll in TRICARE Health Plan
Disenroll in TRICARE Health Plan
Enroll in TRICARE Dental Program

Below are helpful links about your TRICARE eligibility:

DEERS enrollment
Application for a Social Security card

Do you need a pharmacy form?

Sign up for TRICARE home delivery
Submit a request for medical necessity for a drug
Request pre-authorization for a drug, including to use a brand-name drug instead of generic

Do you need a dental form?

Make an appealThe action you take if you don’t agree with a decision made about your benefit.
Request an appointment (active duty service members in remote locations)
Submit a claim
Document dental health from a civilian provider (National Guard and Reserve members)
Submit a fraud complaint or grievanceYou can file a grievance when:
- You have a complaint about the quality of care you received,
- A provider or facility behaved inappropriately, or
- You have any other non-appealable issue.
The grievance may be against any member of your health care team. This includes your TRICARE doctor, your contractor, or a subcontractor. form
Request authorization for disclosure of health information

Click link for all Active Duty Dental Program forms.

Click link for all TRICARE Dental Program forms.

Are you a remotely located Active Duty or Reserve Component service member?

You'll submit forms to Military Medical Support Office (MMSO) at Defense Health Agency-Great Lakes to do the following:

Request pre-authorization for civilian medical care or surgical care
Verify eligibility for medical care
Submit a formal appeal

Do you need to file a claim?

If you need to file a claim for care yourself, visit the Claims section to access the proper form.

Are you looking for another form?

Fees and payments
Prime Travel Benefit
TRICARE For Life
Other health insurance
Privacy forms
TRICARE briefing request

Region-Specific Forms

Check your region's forms page if you don't find what you need here.

East Region (Humana Military)
West Region (Health Net Federal Services)
Overseas (International SOS)

Downloading TRICARE Forms

To download an enrollment form, right-click and select to "save-as" or download direct from the WHS Forms Page. For enrollment, use your region-specific DD-3043 form.

Last Updated 10/4/2022

How do I submit a claim to TriWest?

If submitting a paper claim: Print out and complete the Provider Timely Filing Form on TriWest's Payer Space on Availity, and submit the Provider Timely Filing Form with the paper claim to PGBA.

Does TriWest have a provider portal?

If you have questions about the TriWest Provider Portal at www.triwest.com/provider, please send an email to [email protected].

What is the payer ID for TriWest?

o If you are not certain that you have the correct payer ID, please confirm with your clearinghouse and ensure they are set up to use the correct TriWest EIN: ▪ 841160004 for Region 4 (Western US states) ▪ 841160005 for Region 5 (Alaska) ▪ 841160006 for U.S. Pacific Territories o We are aware of the following ...

What is WPS TriWest?

WPS Military and Veterans Health (WPS MVH) is TriWest's claims processor for the Department of Veterans Affairs' (VA) Veterans Choice Program (VCP) and the Patient-Centered Community Care (PC3) program. Until recently, WPS MVH had different Payer IDs for both the VCP and PC3 programs.