682-RES-Champus Provider CH,/IMPUS TRIC,/JRE Program
Palmetto Government Bendits Administrators
Prorider File Operations
P.O. Bax 202004
Florence~ S.C. 29502-2004
Toll Free1 (800)403-3900 T R I C A
NOTIFICATION OF CHANPUS PROVIPER AUTHORIZATION
April ~0, 1998
City of Sanford Fire Dept
P.O. Box 1788
Sanford, FL 52772
Dear PROVIPER:
XXXX I. We have reviewed your ~ndividual provider applicaf:i. on and have
determined that you meet the eligibiZ'ity requirements to be authorized as a
CHAHPUS provider. You are classified as a/an AHBULANCE. Your prorider number
for fiIing CHANPUS/CHAHPVA claims
PROVIPER ID: 59-6000425
CLASSIFICATION: ANBULANCE
EFFECTIVE DATE: AUGUST I, I996
Please .rite this number on alI cIaims filed by your office and on any
correspondence fo our off~.ce.
Failure to ~ncIude this number on your claims may result in denial of claims
or may affect the timely processing of your cIaims. Please not-ify Prorider
File Operations promptiy of any changes ~n your status or address.
II. We have revieNed your group provider appZication and have determined
that you and your affiliates meet the eiig'ib~.lity requirements to be
authorized as CHANPUS providers. Your group number for fiIing claims
PROVIPER ID:
CLASSIFICATION:
EFFECTIVE DATE:
We have listed the individual providers affiliated N~th your group on the
attached page. You must use your group number and the provider number of each
RENDERING prorider when you file your claims.
Failure to include any of these numbers on your claims may result in denial of
claims or may affect the timely processing of your claims. Please notify
Provider File Operations of any changes ~n your status or address.
RECEIVED
j HUMANA. MAY 0 4 1998 k
ili~ary Healthca~e ServlcesM
CITY OF SAN,FOP-~'
FIRE DF..2T.
CH~tMPUS TRIC,4RE Program
Palmetto Government Benefits Administrators ~
Providor Pile Operations
P.O. Box 202004
FIoronce, $.C. 29502-2004
Toll Free1 (800}403-3950 T R I C A R E
__ III. We have revie,ed your institutional prorider application and have
determined that you meet the eligibility requirements to be authorized as a
CHANPUS institutional prorider. You are classified as a/an institution and
,ill be reimbursed according to payment system. Your prorider number for
filing CHAMPUS/CHAMPVA claims is:
PROVIDER ID:
CLASSIFICATION:
EFFECTIVE DATE=
If your facility has several departments or locations, the specific provider
numbers assigned to each are indicated on the attached page, These 12 digit
numbers MUST be used to ensure proper payment to the correct location,
Failure to include the proper number on your claims may result in denial of
claims or may affect the timely processing of your claims. Please notify
Prorider File Operations promptly of any changes in your status or address.
Prorider File Operations
Post Office Box 100558
Florence, SC 29501-0558
Sincerely,
Barbara Brawn
CHAMPUS Provider File Operations
CHAMPUS TRIC~tRE Program
Palmetto Government Benefits Administrators ~
P.O. Box 202004
Florence, S.C. 29502-2004
Toll Free1 (800}403-3950 T R I C A R E
from page 1, Sects, on TT
Rendering/Departmen;; Name Render;,ng/Depar'~men'~ Provider Number