Tricare Provider Agreement Form

It can take up to 30 days for an application without a network provider to process. You can update your address, phone number, or fax number using the provider`s demographics tool. If you have more than 20 providers and/or sites that need an update or are an Applied Behavior Analysis (ABA) provider, please use our Tricare Provider Group Roster. Non-connected providers can update demographic data by sending an information form to the address of non-connected providers. PGBA`s proprietary electronic exposure system for filing secondary claims with Medicaid can help facilitate the flow of claims between TRICARE and Medicaid and significantly reduce the paperwork required for jackpots. For more information, please contact PGBA`s EDI helpdesk at 1-800-259-0264. Please complete section 9.1 on page 13 (PGBA indicates who to send messages to) A provider that has not signed a network agreement, but meets tricare licensing and certification requirements and is authorized by TRICARE to care for TRICARE beneficiaries. For more information on how to become a non-network provider, see our Become a non-network provider site. ABA providers who wish to become non-network providers must complete an aba application that can be found on our non-network applications site. If you do not have an account, use the automated self-service tools at 1-844-866-WEST (1-844-866-9378). No no. Board Certified Behavior Analysts (BCBAs), Board Certified Assistant Behavior Analysis (BCaBAs), BCBA PhD students (BCBA-Ds), and licensed applied behavior analysis (ABA) providers do not require a Medicare number.

HNFS uses CAQH for its provider network application and connection process. CAQH is a non-profit alliance of the country`s major health plans, including HNFS. All suppliers are required to complete a CAQH online application (and keep their information up to date), with the exception of those located in Idaho, Hawaii, Minnesota and Washington, as an alternative to CAQH is available. (These conditions have special circumstances and the notification process may end with a different entity.) For more information, see our Requirements for The Mental Health Consultant Provider and To Become a Non-Network Provider pages.