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Medical Claim Forms

TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)

In most cases, your provider will file your medical claims for you and you'll receive an explanation of benefits detailing what was paid. Sometimes, you'll need to file your own claims (i.e. when traveling or getting care from a non-participating provider). If you do, you should send your claim form to TRICARE as soon as possible after you receive care.

  • In the U.S. and U.S. territories, claims must be filed within one year of service.
  • In all other overseas areas, claims must be filed within three years of service.
  • All care received overseas is filed with the overseas claims processor.

Submit your claim form along with any supporting documentation to the appropriate claims address.

Statement of Personal Injury-Possible Third Party Liability (DD Form 2527)

Claims submitted with diagnosis codes 800-999 for professional services exceeding $500 and all inpatient services often indicate an accidental injury or illness. When filing these claims, you will have to complete the Third Party Liability Form.

Medicare Health Insurance Claim Form (Form CMS-1500)

The Form CMS-1500 (formally known as HCFA-1500) is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs). A claim is a request for payment of Medicare benefits for services furnished by a health care professional or supplier. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim. >>View CMS-1500 Fact Sheet

Last Updated 4/3/2014