AUGUST 26, 2014
We are pleased to announce that you may now receive ERAs for Tricare West claims. We have attached the ERA application with instructions on how to complete the application. Once the application has been filled out and faxed to Tricare you will then be able to receive ERA’s in Procentive for easier posting of payments.
This application must be completed by a staff member that has signing authority. All completed applications MUST be faxed to be Tricare and Procentive.
1. Download the ERA application PDF (see below)
2. On page 2 “ERA Enrollment Form” please complete the following fields:
· Provider Information: Enter in your company name as it appears on your tax
· Provider Address: Enter in your billing address.
· Provider Identifiers Information: Enter in your group Tax ID and group NPI only. Please leave the “Other identifier(s)” and “Trading Partner ID” fields as is.
-In the “NOTE:” section, please place a check in the box.
-Do not complete the “Tricare Provider Number”, “National Provider Identifier (NPI)”, or the “Business Name and Address” fields.
· Provider Contact Information: Please enter in the name of the staff name and phone number that should be contacted if there are any questions or concerns about the application.
3. On page 3, please complete the following fields:
· Email Address: Enter the email for the contact staff from page 2.
· Fax Number: Enter in the fax number for the contact staff from page 2.
· Electronic Remittance Advice Information: In the “Provider tax identification number (TIN) or National Provider Number (NPI)” field, please enter your group NPI. Please leave all other fields as is and go to the bottom of page 3.
· Authorized Signature: Type/write in the signature of the person submitting this form (this must be a staff that has authority to sign applications for payers), enter their title (CEO, Business Manager, Owner, etc.), the submission date (date you are faxing the application), and “Requested ERA Effective Date” this must be the same date as the submission date. ERAs cannot be backdated.
4. Pages 4 & 5 contain more detailed definitions of the fields, if needed.
5. Once the application is complete, please fax the following:
All 5 pages to:
Attn: Tricare EDI
Fax # 803-264-9864.
A copy to:
Fax #888-354-9053 (or attach the application to a ticket)