HTML Preview Provider Correspondence Fax Cover Sheet For Medical Printable page number 1.
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Provider Correspondence Fax Cover Sheet
To: TRICARE South Region Claims Fax: _____________________
From: _____________________________ Fax: _____________________
Number of pages (including cover sheet): _____
Patient Name: ________________________________________________
Date(s) of Service: ________________________________________________
TRICARE Claim Number: ________________________________________________
Tax Identification Number: ________________________________________________
(on claim)
Reason for Correspondence
__ - Corrected Claim: Corrections to be made: _____________________________________________
_________________________________________________________________
__ - Referral Information from PCM (claims processed with Point of Service Option)
__ - Duplicate Review – Supporting medical documentation for services denied as a Duplicate
__ - ClaimCheck Review – Supporting medical documentation for services denied per ClaimCheck
__ - Claim Appeal Request
__ - Other: ________________________________________________________________________
Please use the appropriate secure FAX number from the list below:
Routine Correspondence: 803-462-3993 Third Party Liability Forms: 803-462-3987
Other Health Insurance Updates: 803-462-3981 Durable Medical Equipment: 803-462-3982
Authorizations/Referrals: 877-548-1547 Authorization to Disclose Information: 803-462-3984
08/14