Overview

How to Read Your TRICARE Summary Payment Voucher:

  1. Correspondence address for PGBA, LLC, your region's TRICARE Claims Administrator.
  2. The name and logo of the Prime contractor, the managed care support contractor for your TRICARE region.
  3. The toll-free phone number/Web address for PGBA, your TRICARE Claims Administrator.
  4. The date PGBA prepared this TRICARE payment voucher.
  5. Social Security Number (SSN) or TIN of the provider who performed the services.
  6. Number of the check issued as payment for the claim(s).
  7. Number of this page followed by the total number of pages.
  8. The patient's account number assigned by the provider's office and the patient's name.
  9. SSN or TIN of the provider who performed the services or the provider's National Association of Boards of Pharmacy number.
  10. The SSN of the military service member (active duty, retired or deceased).
  11. Beginning and ending dates the services were performed.
  12. CPT4 procedure code(s) or HCPCS equipment code(s) that identify the service(s) the provider performed.
  13. The number of services the provider performed.
  14. Total amount the provider billed for the services.
  15. Amount TRICARE approves for the services.
  16. This code corresponds to an explanation on the last page of how this claim was paid.
  17. This code corresponds to a message on the last page that explains more about your claims payment.
  18. Amounts subtracted from the total payment that are the patient's responsibility to pay.
  19. Amount TRICARE has paid for the billed services.
  20. If the claim was paid as DRG, the Diagnosis Related Group number would appear.
  21. Total amounts for the claim and the amount other health insurance paid.
  22. The amount the patient must pay the provider, including cost-shares, copayments, deductibles and non-covered charges.