Please follow the Enrollment Instructions below to become an electronic submitter to Palmetto GBA for your Tricare West claims.

The following documents are required enrollment documents that must be completed, signed and returned to the PGBA office prior to initiation of electronic claims submission or inquiry.

1. Clearinghouse/Direct Submitter Trading Partner Agreement (Fill out this form if you will be sending claims directly to Tricare)

2. HIPAA EDI Provider Agreement (Fill out this form if you will be sending Tricare claims through a clearinghouse or billing service)

If the above links do not work properly, download the forms listed above from here:
http://www.mytricare.com/internet/tric/tri/mtc_nprov.nsf/sectionmap/Elct...

3. EDIG Trading Partner Enrollment Form

If the above link does not work properly, download the form listed above from here:
http://204.28.103.156/enrollmentandagreements/hospitalandphysiciantradin...

4. ERA Enrollment Form

If the above link does not work properly, download the form listed above from here:
http://www.mytricare.com/internet/tric/tri/mtc_nprov.nsf/sectionmap/Frms...

5. SFTP-VPN Customer Connectivity Parameter Survey

If the above link does not work properly, download the form listed above from here:

https://www.tricare-west.com/content/hnfs/home/tw/prov/res/provider_forms/edi.html

If you have any questions regarding any of the documents in this package, please phone the PGBA EDI Technology Support Center at 1-800-259-0264.

We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.

Clearinghouse/Direct Submitter Trading Partner Agreement

Fill out this form if you will be submitting your claims directly to Tricare

• Please leave the Agreement Number line blank

• Enter today’s date and your Business/Practice or Provider name in the first paragraph (You are the Trading Partner)

• Please complete section 9.1 on page 13 with your information (This tells PGBA who they should send notices to)

• Complete the Trading Partner section on the left side of page 16

• Complete Exhibit A

  • Enter your information in the Trading Partner section

  • Please enter the information for the software or vendor that creates your 837 files you need Claimshuttle to transfer for you. If you have paid for our SolAce billing software, please call our support line for our SolAce software information.

  • If you are a provider using a Billing Service, please enter the Billing Services information in the Billing Service Information section

• On Exhibit A Page 2 Please Write in under Means of Electronic Access " Secure FTP" and write in "Will use AXIOM Systems Inc's IP and Certificate"

HIPAA EDI Provider Agreement

(To be completed only by provider’s who will be billing via a Billing Service)
Billing Services: Your providers must fill out this form to authorize you to submit their Tricare Billings.

Providers with a Billing Service please sign and date Section C of this form

• For Contact Name, please enter the name of the main contact person for your office

• For Billing Service Name/ Vendor, please enter your billing services information

• On the last page of this form, please list your Tricare Number, Name, and Demographic information

EDIG Trading Partner Enrollment Form

• Enter today’s date

• New applicants, please select “New Trading Partner ID”

• Complete the Trading Partner Name field with your Business/Practice or Provider name

• Leave the Trading Partner ID line blank if you are applying for a new ID and fill in your Tax ID in the Tax ID line

• For Type of Business select either Institutional or Professional

  • If you are a Billing Service, please choose Billing Service

• For Line of Business, please choose “PGBA LLC”

• Enter today’s date for the start date and leave the end date blank

• Compression: choose PKZIP

• Protocol: choose Secure FTP ( on the right in the blank area write in "will use AXIOM Systems Inc's IP and Certificate" )

• Complete your address and contact information.

• For Transactions, choose:

  • ASC X12N 835 for Electronic Remits (EOB's)

  • ASC X12N 837I for Institutional, or

  • ASC X12N 837P for Professional

  • For every transaction checked, provide an average number of transactions submitted weekly

• For Vendor’s information Please enter the information for the software or vendor that creates your 837 files you need Claimshuttle to transfer for you. If you have paid for our SolAce billing software please call our support line for our SolAce software information.

• Complete the Customers Information section with your information

• Leave the last page blank

SFTP/VPN Customer Connectivity Parameter Survey

• Enter your information in the first section

  • Business Contact Name, Phone and Email

  • Technical Contact Name, Phone and Email

  • Company Name, Phone and Address

• Please leave the entire VPN Section Blank

• On the right, the SFTP side, please enter:

  • "Use Axiom's IP Address" for the Customer Static Public IP

  • For Customer FTP Client Software please enter "Use Axiom's SSH Key"

ERA Enrollment Form

Note: Do not send this in with your enrollment packet. You must wait for your Submitter ID to be assigned prior to completing this form.

• Please enter your Provider name and address

• Please enter your Tax ID and NPI

• Enter your Tricare Provider number and your assigned Tricare Submitter ID

• List your Tricare Provider numbers, NPI's, and names

• Enter your Provider contact information

• Please enter either your NPI or Tax ID

• In the box next to "Method of Retrieval" please type in "Direct"

• Leave the Clearinghouse section blank

• Check the box for "New Enrollment"

• Please sign, enter your title, and today's date for both the Submission Date and the Requested ERA Effective Date

Submitting your Forms

It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to the following addresses:

 

Send the Electronic Provider Trading Partner Agreements and EDIG Trading Partner Enrollment to:

 

Palmetto GBA, EDIG Operations

PO Box 17151 

Augusta, GA 30903

Send All ERA Enrollments and HIPAA EDI Provider Agreement form (if using Billing Service) to:

 

TRICARE PGBA, LLC
TRICARE Electronic Data Interchange
PO Box 202007
Florence, SC 29502-2007

It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.

Waiting for a Response

Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)

After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the PGBA, LLC EDI Technology Support Center at 1-800-259-0264.

Testing

Once you have received your Submitter ID and Password from PGBA, LLC, please call the Claimshuttle Support Team at 602-439-2525 and set an appointment for a Mailbox setup and Test Transmission.

Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.