Provider forms

Claims Behavioral health Pharmacy Misc
Certificate of Medical Necessity (CMN)
Proactive recoupment form
Claim form (DD 2642)
Reconsideration coversheet/ tipsheet
Noncovered services waiver form
Behavioral health continued stay request
Recoupment tip sheet for ABA providers
Behavioral health discharge form
Referral for Applied Behavior Analysis
Behavioral health initial request
Request for Applied Behavior Analysis (Reassessment)
Brexanolene (ZULRESSO) therapy treatment request
Residential Treatment Center (RTC) concurrent review
Clinical diagnosis: DSM-5 diagnostic checklist
Residential Treatment Center (RTC) initial review
Electroconvulsive Therapy (ECT)
Spravato (Esketamine) initial request form
Initial request for Applied Behavior Analysis
Spravato (Esketamine) continued request form
Outpatient/Ambulatory Opiate and Substance Use Disorder (SUD)
Transcranial Magnetic Stimulation (TMS)
Accredo prescription enrollment form
US Bioservices patient enrollment form
Accredo drug therapy search
Accredo prescription enrollment form
Medex BioCare general injectable prescription and enrollment form
Authorized signer form
Provider information update request form
Care management open referral form
Important message from TRICARE
Continuous glucose monitor attestation form
Request for Banked Donor Milk (BDM)
Standard Acquisition Charges (SAC) for organ acquisition
Laboratory Developed Tests (LDT) attestation form
Medical record request/tipsheet
Reimbursement of capital and direct medical education costs
Concurrent hospice and curative care monthly service activity log
Provider roster load issues
Change TIN form
Provider roster update: Non-delegated
Provider roster update: Delegated
PRO agreement

To participate in the care of TRICARE beneficiaries, facilities must establish a Peer Review Organization (PRO) agreement with Humana Military in accordance with 32 CFR 199.15(g).
Patient referral authorization

Referrals and authorizations must be submitted through provider self-service.
W9 form

FAQs, tipsheets and more

FAQs Tipsheets Presentations Misc
Appeal submission process
Provider eligibility
Claim status policy
Provider roster upload self-service
Clear and Legible Reports (CLR)
Reconsideration
Freestanding Emergency Room (ER)
Recoupment summary search via provider self-service
Patient eligibility in provider self-service FAQs
Behavioral healthcare services
TRICARE covered clinical preventive services
Eligibility and Benefit Inquiry (270) and Eligibility and Benefit Response (271)
TRICARE DME guidelines
Pediatric PCM information
TRICARE Prime and Select comparison
How to submit claims documents
TRICARE referrals and prior authorizations
Provider claims submission
TRICARE Right of First Refusal process
Provider resources
Using provider self-service
Recoupment tip sheet for Applied Behavior Analysis (ABA) providers
Provider orientation
Approach to code editing
Care Considerations and provider feedback
Patient eligibility verification in provider self-service
DHA Healthcare Provider Recommendations to Support Patients Exposed to the November 2021 Fuel Release at Red Hill
Naval Health Clinic Hawaii Red Hill Clinic (for those on-island):
DHA’s Red Hill Public Health information page
Email questions to dha.redhill@health.mil