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pdf- PATIENT'S COPY TRICARE DoD/CHAMPUS MEDICAL CLAIM
PATIENT'S REQUEST FOR MEDICAL PAYMENT
OMB No. 0720-0006
OMB approval expires
Aug 31, 2009
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0720-0005). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE
APPROPRIATE CLAIMS PROCESSOR. IF YOU DO NOT KNOW WHO YOUR CLAIMS PROCESSOR IS, CONTACT A BENEFICIARY
COUNSELING AND ASSISTANCE COORDINATOR (BCAC) OR TRICARE MANAGEMENT ACTIVITY (303) 676-3400.
PRIVACY ACT STATEMENT
AUTHORITY: 44 U.S.C. 3101; 10 U.S.C. 1079 and 1086; 38 U.S.C. 1781; E.O. 9397.
PRINCIPAL PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility
and determination that the services/supplies received are authorized by law.
ROUTINE USE(S): Information from claims and related documents may be given to the Department of Health and Human Services and/or the
Department of Homeland Security consistent with their statutory administrative responsibilities under CHAMPUS; to the Department of Justice for
representation of the Secretary of Defense in civil actions; to the Internal Revenue Service and private collection agencies in connection with
recoupment claims; and to Congressional offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate
disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on
matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity,
third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS.
DISCLOSURE: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim.
IMPORTANT - READ CAREFULLY
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, fictitious or fraudulent statement
or claim in any matter within the jurisdiction of any department or agency of the United States. Examples of fraud include situations in which ineligible
persons knowingly use an unauthorized Identification Card in filing of a CHAMPUS claim; or where providers submit claims for treatment, supplies or
equipment not rendered to, or used for TRICARE DoD/CHAMPUS beneficiaries; or where a participating provider bills the beneficiary/patient (or
sponsor) for amounts over the CHAMPUS-determined allowable charge; or where a beneficiary/patient (or sponsor) fails to disclose other medical
benefits or health insurance coverage.
INCOMPLETE CLAIM FORMS WILL DELAY PAYMENT
NONAVAILABILITY STATEMENT REQUIREMENTS: If the patient resides within the catchment area of a Military Treatment Facility (MTF)
(generally within a 40-mile radius of the MTF), you will need to obtain a Nonavailability Statement (NAS) from the MTF for a hospital admission for
mental health that is not a bona fide emergency. Without a necessary NAS your claim will be denied.
******
ITEMIZED BILL: Ask your provider to complete the HCFA Form 1500 for you. If the provider refuses, complete this form and attach an itemized bill
which must be on the provider's billing letterhead. The bill must contain the following information:
1. Doctor's or provider's name/address (the one that actually provided your care). If there is more than one provider on the bill, circle
his/her name;
2. Date of each service;
3. Place of each service;
4. Description of each surgical or medical service or supply furnished;
5. Charge for each service;
6. The diagnosis should be included on the bill. If not, make sure that you've completed block 8a on the form.
DRUGS: Prescription claims require the name of the patient; the name, strength, date filled, days supply, quantity dispensed, and price of each
drug; NDC for each drug if available; the prescription number of each drug; the name and address of the pharmacy; and the name and address
of the prescribing physician. Billing statements showing only total charges, or canceled checks, or cash register and similar type receipts are not
acceptable as itemized statements, unless the receipt provides detailed information required above.
******
TIMELY FILING REQUIREMENTS: All claims must be filed no later than one year after the services are provided; or for inpatient care, one year from
the date of discharge. If a claim is returned for additional information, it must be resubmitted by the filing deadiline, or within 90 days of the notice -whichever date is later.
******
WHERE TO OBTAIN ADDITIONAL FORMS: You may obtain additional claim forms from your claims processor, the TRICARE Service Center at the
nearest military treatment facility or TRICARE Management Activity, 16401 E. Centretech Pkwy., Aurora, CO 80011-9066.
* * * REMINDER * * *
Before submitting your claim to the claims processor be sure that you have:
1.
2.
3.
4.
5.
6.
Completed all 12 blocks on the form. If not signed, the claim will be returned.
Verified that the sponsor's SSN is correct.
Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.
Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.
Obtained a Nonavailability Statement if required (see information above).
Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity" if accident
or work related. See instruction number 7 on reverse side.
7. Ensured that patient's name, sponsor's name and sponsor's SSN are on all attachments.
8. Made a copy of this claim and attachments for your records.
DD FORM 2642, APR 2007
PREVIOUS EDITION IS OBSOLETE.
COPY 1 - PATIENT'S COPY
Adobe Professional 7.0
- PATIENT'S COPY 1. PATIENT'S NAME (Last, First, Middle Initial)
2. PATIENT'S TELEPHONE NUMBER (Include Area Code)
3. PATIENT'S ADDRESS (Street, Apt. No., City, State, and ZIP Code)
DAYTIME (
)
EVENING (
)
4. PATIENT'S RELATIONSHIP TO SPONSOR (X one)
5. PATIENT'S DATE OF BIRTH
(YYYYMMDD)
SELF
STEPCHILD
SPOUSE
FORMER SPOUSE
NATURAL OR ADOPTED CHILD
OTHER (Specify)
7. IS PATIENT'S CONDITION (X both if applicable)
6. PATIENT'S SEX
(X one)
ACCIDENT RELATED?
WORK RELATED?
MALE
FEMALE
8a. DESCRIBE CONDITION FOR WHICH THE PATIENT RECEIVED TREATMENT, SUPPLIES OR
MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED. REFER TO INSTRUCTIONS BELOW.
YES
NO
YES
NO
8b. WAS PATIENT'S CARE (X one)
INPATIENT?
PHARMACY?
OUTPATIENT?
DAY SURGERY?
10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY NUMBER
9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle
Initial)
11. OTHER HEALTH INSURANCE COVERAGE
a. Is patient covered by any other health insurance plan or program to include health coverage available through other family members?
If yes, check the "Yes" block and complete blocks 11 and 12 (see instructions below). If no, you must check the "No" block and
complete block 12. Do not provide TRICARE/CHAMPUS supplemental insurance information, but do report Medicare supplements.
b. TYPE OF COVERAGE (Check all that apply)
(3) MEDICARE
(1) EMPLOYMENT (Group)
(2) PRIVATE (Non-Group)
(5) MEDICARE SUPPLEMENTAL INSURANCE
(4) STUDENT PLAN
YES
NO
(7) OTHER (Specify)
(6) PRESCRIPTION DISCOUNT PLAN
c. NAME AND ADDRESS OF OTHER HEALTH INSURANCE
(Street, City, State, and ZIP Code)
d. INSURANCE IDENTIFICATION
NUMBER
e. INSURANCE
EFFECTIVE DATE f. DRUG
COVERAGE?
(YYYYMMDD)
INSURANCE
YES
1
NO
INSURANCE
YES
2
NO
REMINDER: Attach your other health insurances's Explanation of Benefits or pharmacy receipt that indicates the actual drug cost,
amount the OHI paid, and the amount that you paid.
13. OVERSEAS CLAIMS ONLY:
12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND
PAYMENT IN LOCAL
AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.
CURRENCY?
a. SIGNATURE
b. DATE SIGNED
c. RELATIONSHIP TO PATIENT
(YYYYMMDD)
YES
NO
HOW TO FILL OUT THE TRICARE/CHAMPUS FORM
You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.
1. Enter patient's last name, first name and middle initial as it appears on the
military ID Card. Do not use nicknames.
2. Enter the patient's daytime telephone number and evening telephone
number to include the area code.
3. Enter the complete address of the patient's place of residence at the time of
service (street number, street name, apartment number, city, state, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and numbers.
Do not use an APO/FPO address unless the patient was actually residing
overseas when care was provided.
4. Check the box to indicate patient's relationship to sponsor. If "Other" is
checked, indicate how related to the sponsor; e.g., parent.
5. Enter patient's date of birth (YYYYMMDD).
6. Check the box for either male or female (patient).
7. Check box to indicate if patient's condition is accident related, work related
or both. If accident or work related, the patient is required to complete DD
Form 2527, "Statement of Personal Injury - Possible Third Party Liability
TRICARE Management Activity." The form may be obtained from the claims
processor, BCAC, or TRICARE Management Activity.
8a. Describe patient's condition for which treatment was provided, e.g., broken
arm, appendicitis, eye infection. If patient's condition is the result of an injury,
report how it happened, e.g., fell on stairs at work, car accident.
8b. Check the box to indicate where the care was given.
9. Enter the Sponsor's or Former Spouse's last name, first name and middle
initial as it appears on the military ID Card. If the sponsor and patient are the
same, enter "same."
10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN).
DD FORM 2642 (BACK), APR 2007
11. By law, you must report if the patient is covered by any other health insurance to
include health coverage available through other family members. If the patient has
supplemental TRICARE/CHAMPUS insurance, do not report. You must, however,
report Medicare supplemental coverage. Block 11 allows space to report two
insurance coverages. If there are additional insurances, report the information as
required by Block 11 on a separate sheet of paper and attach to the claim.
NOTE: All other health insurances except Medicaid and TRICARE/CHAMPUS
supplemental plans must pay before TRICARE/CHAMPUS will pay. With the
exception of Medicaid and CHAMPUS supplemental plans, you must first submit the
claim to the other health insurer and after that insurance has determined their
payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to
this claim. The claims processor cannot process claims until you provide the other
health insurance information.
12. The patient or other authorized person must sign the claim. If the patient is
under 18 years old, either parent may sign unless the services are confidential and
then the patient should sign the claim. If the patient is 18 years or older, but cannot
sign the claim, the person who signs must be either the legal guardian, or in the
absence of a legal guardian, a spouse or parent of the patient. If other than the
patient, the signer should print or type his/her name in Block 12a. and sign the claim.
Attach a statement to the claim giving the signer's full name and address,
relationship to the patient and the reason the patient is unable to sign. Include
documentation of the signer's appointment as legal guardian, or provide your
statement that no legal guardian has been appointed. If a power of attorney has
been issued, provide a copy.
13. If this is a claim for care received overseas, indicate if you want payment in the
local currency. NOTE: Payment available only in some local currencies.
Reset
COPY 1 - PATIENT'S COPY
OMB No. 0720-0006
OMB approval expires
Aug 31, 2009
TRICARE DoD/CHAMPUS MEDICAL CLAIM
PATIENT'S REQUEST FOR MEDICAL PAYMENT
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0720-0005). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE
APPROPRIATE CLAIMS PROCESSOR. IF YOU DO NOT KNOW WHO YOUR CLAIMS PROCESSOR IS, CONTACT A BENEFICIARY
COUNSELING AND ASSISTANCE COORDINATOR (BCAC) OR TRICARE MANAGEMENT ACTIVITY (303) 676-3400.
PRIVACY ACT STATEMENT
AUTHORITY: 44 U.S.C. 3101; 10 U.S.C. 1079 and 1086; 38 U.S.C. 1781; E.O. 9397.
PRINCIPAL PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility
and determination that the services/supplies received are authorized by law.
ROUTINE USE(S): Information from claims and related documents may be given to the Department of Health and Human Services and/or the
Department of Homeland Security consistent with their statutory administrative responsibilities under CHAMPUS; to the Department of Justice for
representation of the Secretary of Defense in civil actions; to the Internal Revenue Service and private collection agencies in connection with
recoupment claims; and to Congressional offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate
disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on
matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity,
third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS.
DISCLOSURE: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim.
IMPORTANT - READ CAREFULLY
Federal Laws (18 U.S.C. 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, fictitious or fraudulent statement
or claim in any matter within the jurisdiction of any department or agency of the United States. Examples of fraud include situations in which ineligible
persons knowingly use an unauthorized Identification Card in filing of a CHAMPUS claim; or where providers submit claims for treatment, supplies or
equipment not rendered to, or used for TRICARE DoD/CHAMPUS beneficiaries; or where a participating provider bills the beneficiary/patient (or
sponsor) for amounts over the CHAMPUS-determined allowable charge; or where a beneficiary/patient (or sponsor) fails to disclose other medical
benefits or health insurance coverage.
INCOMPLETE CLAIM FORMS WILL DELAY PAYMENT
NONAVAILABILITY STATEMENT REQUIREMENTS: If the patient resides within the catchment area of a Military Treatment Facility (MTF)
(generally within a 40-mile radius of the MTF), you will need to obtain a Nonavailability Statement (NAS) from the MTF for a hospital admission for
mental health that is not a bona fide emergency. Without a necessary NAS your claim will be denied.
******
ITEMIZED BILL: Ask your provider to complete the HCFA Form 1500 for you. If the provider refuses, complete this form and attach an itemized bill
which must be on the provider's billing letterhead. The bill must contain the following information:
1. Doctor's or provider's name/address (the one that actually provided your care). If there is more than one provider on the bill, circle
his/her name;
2. Date of each service;
3. Place of each service;
4. Description of each surgical or medical service or supply furnished;
5. Charge for each service;
6. The diagnosis should be included on the bill. If not, make sure that you've completed block 8a on the form.
DRUGS: Prescription claims require the name of the patient; the name, strength, date filled, days supply, quantity dispensed, and price of each
drug; NDC for each drug if available; the prescription number of each drug; the name and address of the pharmacy; and the name and address
of the prescribing physician. Billing statements showing only total charges, or canceled checks, or cash register and similar type receipts are not
acceptable as itemized statements, unless the receipt provides detailed information required above.
******
TIMELY FILING REQUIREMENTS: All claims must be filed no later than one year after the services are provided; or for inpatient care, one year from
the date of discharge. If a claim is returned for additional information, it must be resubmitted by the filing deadiline, or within 90 days of the notice -whichever date is later.
******
WHERE TO OBTAIN ADDITIONAL FORMS: You may obtain additional claim forms from your claims processor, the TRICARE Service Center at the
nearest military treatment facility or TRICARE Management Activity, 16401 E. Centretech Pkwy., Aurora, CO 80011-9066.
* * * REMINDER * * *
Before submitting your claim to the claims processor be sure that you have:
1.
2.
3.
4.
5.
6.
Completed all 12 blocks on the form. If not signed, the claim will be returned.
Verified that the sponsor's SSN is correct.
Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.
Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.
Obtained a Nonavailability Statement if required (see information above).
Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity" if accident
or work related. See instruction number 7 on reverse side.
7. Ensured that patient's name, sponsor's name and sponsor's SSN are on all attachments.
8. Made a copy of this claim and attachments for your records.
DD FORM 2642, APR 2007
PREVIOUS EDITION IS OBSOLETE.
COPY 2 - PROCESSOR'S COPY
1. PATIENT'S NAME (Last, First, Middle Initial)
2. PATIENT'S TELEPHONE NUMBER (Include Area Code)
3. PATIENT'S ADDRESS (Street, Apt. No., City, State, and ZIP Code)
DAYTIME (
)
EVENING (
)
4. PATIENT'S RELATIONSHIP TO SPONSOR (X one)
5. PATIENT'S DATE OF BIRTH
(YYYYMMDD)
SELF
STEPCHILD
SPOUSE
FORMER SPOUSE
NATURAL OR ADOPTED CHILD
OTHER (Specify)
7. IS PATIENT'S CONDITION (X both if applicable)
6. PATIENT'S SEX
(X one)
ACCIDENT RELATED?
WORK RELATED?
MALE
FEMALE
8a. DESCRIBE CONDITION FOR WHICH THE PATIENT RECEIVED TREATMENT, SUPPLIES OR
MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED. REFER TO INSTRUCTIONS BELOW.
YES
NO
YES
NO
8b. WAS PATIENT'S CARE (X one)
PHARMACY?
INPATIENT?
OUTPATIENT?
DAY SURGERY?
10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY NUMBER
9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle
Initial)
11. OTHER HEALTH INSURANCE COVERAGE
a. Is patient covered by any other health insurance plan or program to include health coverage available through other family members?
If yes, check the "Yes" block and complete blocks 11 and 12 (see instructions below). If no, you must check the "No" block and
complete block 12. Do not provide TRICARE/CHAMPUS supplemental insurance information, but do report Medicare supplements.
YES
NO
b. TYPE OF COVERAGE (Check all that apply)
(1) EMPLOYMENT (Group)
(3) MEDICARE
(2) PRIVATE (Non-Group)
(4) STUDENT PLAN
(5) MEDICARE SUPPLEMENTAL INSURANCE
(6) PRESCRIPTION DISCOUNT PLAN
c. NAME AND ADDRESS OF OTHER HEALTH INSURANCE
(Street, City, State, and ZIP Code)
(7) OTHER (Specify)
e. INSURANCE
EFFECTIVE DATE f. DRUG
COVERAGE?
(YYYYMMDD)
d. INSURANCE IDENTIFICATION
NUMBER
INSURANCE
YES
1
NO
INSURANCE
YES
2
NO
REMINDER: Attach your other health insurances's Explanation of Benefits or pharmacy receipt that indicates the actual drug cost,
amount the OHI paid, and the amount that you paid.
13. OVERSEAS CLAIMS ONLY:
12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND
PAYMENT IN LOCAL
AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.
CURRENCY?
a. SIGNATURE
b. DATE SIGNED
c. RELATIONSHIP TO PATIENT
(YYYYMMDD)
YES
NO
HOW TO FILL OUT THE TRICARE/CHAMPUS FORM
You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.
1. Enter patient's last name, first name and middle initial as it appears on the
military ID Card. Do not use nicknames.
2. Enter the patient's daytime telephone number and evening telephone
number to include the area code.
3. Enter the complete address of the patient's place of residence at the time of
service (street number, street name, apartment number, city, state, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and numbers.
Do not use an APO/FPO address unless the patient was actually residing
overseas when care was provided.
4. Check the box to indicate patient's relationship to sponsor. If "Other" is
checked, indicate how related to the sponsor; e.g., parent.
5. Enter patient's date of birth (YYYYMMDD).
6. Check the box for either male or female (patient).
7. Check box to indicate if patient's condition is accident related, work related
or both. If accident or work related, the patient is required to complete DD
Form 2527, "Statement of Personal Injury - Possible Third Party Liability
TRICARE Management Activity." The form may be obtained from the claims
processor, BCAC, or TRICARE Management Activity.
8a. Describe patient's condition for which treatment was provided, e.g., broken
arm, appendicitis, eye infection. If patient's condition is the result of an injury,
report how it happened, e.g., fell on stairs at work, car accident.
8b. Check the box to indicate where the care was given.
9. Enter the Sponsor's or Former Spouse's last name, first name and middle
initial as it appears on the military ID Card. If the sponsor and patient are the
same, enter "same."
10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN).
DD FORM 2642 (BACK), APR 2007
11. By law, you must report if the patient is covered by any other health insurance to
include health coverage available through other family members. If the patient has
supplemental TRICARE/CHAMPUS insurance, do not report. You must, however,
report Medicare supplemental coverage. Block 11 allows space to report two
insurance coverages. If there are additional insurances, report the information as
required by Block 11 on a separate sheet of paper and attach to the claim.
NOTE: All other health insurances except Medicaid and TRICARE/CHAMPUS
supplemental plans must pay before TRICARE/CHAMPUS will pay. With the
exception of Medicaid and CHAMPUS supplemental plans, you must first submit the
claim to the other health insurer and after that insurance has determined their
payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to
this claim. The claims processor cannot process claims until you provide the other
health insurance information.
12. The patient or other authorized person must sign the claim. If the patient is
under 18 years old, either parent may sign unless the services are confidential and
then the patient should sign the claim. If the patient is 18 years or older, but cannot
sign the claim, the person who signs must be either the legal guardian, or in the
absence of a legal guardian, a spouse or parent of the patient. If other than the
patient, the signer should print or type his/her name in Block 12a. and sign the claim.
Attach a statement to the claim giving the signer's full name and address,
relationship to the patient and the reason the patient is unable to sign. Include
documentation of the signer's appointment as legal guardian, or provide your
statement that no legal guardian has been appointed. If a power of attorney has
been issued, provide a copy.
13. If this is a claim for care received overseas, indicate if you want payment in the
local currency. NOTE: Payment available only in some local currencies.
Reset
COPY 2 - PROCESSOR'S COPY
| File Type | application/pdf |
| File Title | DD Form 2642, TRICARE DoD/CHAMPUS Medical Claim - Patient's Request for Medical Payment, April 2007 |
| Author | WHS/ESD/IMD |
| File Modified | 2007-04-19 |
| File Created | 2007-04-18 |