Provider Certification Application

Organization information

For TRICARE providers

Federal Law (5 U.S.C. 5536) prohibits medical personnel, who are Active Duty Service Members (ADSM) or civilian employees of the government, compensation above their normal pay and allowances for medical care rendered. This prohibition applies to TRICARE benefits whether the claim for reimbursement is filed by the individual who provided the care, the facility in which the care was rendered, or by the sponsor/beneficiary. Claims for TRICARE benefits will be denied in any situation where either a uniform member or civilian employee of the uniform services has the opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries to one or more providers on a selective basis.

Organization information

Missing or invalid information will delay the processing of the certification application, or result in rejection of the application.

Organization name (DBA):* Organization tax ID:* Organization National Provider Identifier (NPI):*
Organization physical street address (PO box not allowed):* Organization physical apt/suite/other: Organization physical address city:* Organization physical address ZIP Code:* Organization phone # (No dashes):* I do not have a fax number Organization fax #(No dashes):* Is billing address same as physical address?: Yes
Organization billing street address:* Organization billing apt/suite/other: Organization billing address city:* Organization billing address ZIP Code:*

Organization billing phone # (No dashes):* Corporate ownership name:*

Ages Served

Correspondence/Point of Contact information

Identify the person available to answer questions about this TRICARE certification application and the address where you would like to receive correspondence related to your application.

Certification Point of Contact(POC) name:* Certification Point of Contact(POC) street address:* Certification Point of Contact(POC) apt/suite/other: Certification Point of Contact(POC) city:* Certification Point of Contact(POC) ZIP Code:* Certification Point of Contact(POC) phone #(No dashes):* Certification Point of Contact(POC) email:* Certification Point of Contact(POC) email:*

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State license/certificate Information:

State license/certificate information

State license classification: State license/certificate number: Effective date (MM-DD-YYYY): Expiration date (MM-DD-YYYY): Note: If License does not expire use 12-31-9999.
Please upload state license. If state does not offer license, please upload supporting documentation stated in comments. Upload license

Any disciplinary action: Yes: No:
The state in which this organization is located does not offer a state license or certificate:(checkbox):

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Other license information:

Medicare certification number

Medicare number: Effective date (MM-DD-YYYY): Upload medicare certificate

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Participation agreement:

TRICARE Reimbursement Manual, Chapter 8 Addendum A
Skilled nursing facility provider participation agreement

Corporate name:*

DBA (if different than corporate name):*

Address:*

City:*

State:*

ZIP Code:*

Mailing Address(if different):*

City:*

State:*

ZIP Code:*

Telephone:*

Provider EIN:*

Agreement between TRICARE and DBA

Medicare provider #:

In order to receive payment under 32 Code of Federal Regulations (CFR) Part 199, DBA as the Provider of skilled nursing services agrees to conform the provisions of 32 CFR 199 and applicable provisions in TRICARE Manuals and applicable Medicare provisions in 42 CFR. This Agreement, upon submission by the Provider of skilled nursing services of acceptable assurance of compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by TRICARE, shall be binding on the Provider of skilled nursing services and TRICARE. The Provider of skilled nursing services certifies that:

a) The Provider is licensed by the State having jurisdiction from the Provider’s area.
b) The Provider is Medicare certified and will continue to maintain Medicare certification.
If at any time the provider is decertified by Medicare, the provider agrees to notify the TRICARE contractor within 72 hours. Loss of Medicare certification will nullify this agreement.
c) The Provider will not discriminate against the TRICARE beneficiary in their admission practices or in delivery of medically necessary services due to the level of payment.
d) The Provider will use the same certification forms for TRICARE patients as are used and required for Medicare patients. The provider will provide notices to TRICARE beneficiaries in the same manner as they provide under Medicare.
e) The Provider will participate on all TRICARE claims for admissions under SNF prospective payment system (PPS), and will accept TRICARE payment as the full payment and not balance bill the TRICARE beneficiaries. The Provider will collect the applicable costshare amounts from the TRICARE beneficiaries.
In the event of a transfer of ownership, this Agreement is automatically assigned to the new owner subject to the conditions specified in this Agreement and 42 CFR 489, to include existing plans of correction and the duration of this Agreement, if the Agreement is time limited.

Facility name:

By checking this checkbox, I acknowledge and agree to the above participation agreement and by typing my name and title into the fields below hereby submit my electronic signature. This agreement must be signed by the chief executive officer (CEO), or designee. *

Name and title:*

Executed on (date):*

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Attestation:

I confirm that the above information is true and complete to the best of my knowledge by typing my name in the box below.

Electronic signature (Do not include middle initial):* Attested date:*

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