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