Get Wi Tricare 31576-097 2023-2026

The WI Tricare 31576-097 form is essential for requesting authorization for skilled nursing facility services under TRICARE for Life. This guide provides step-by-step instructions to help you accurately complete the form online.

Follow the steps to successfully complete the authorization request.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Fill out the provider information section. Include the facility name, address, city, state, and zip code. Also, provide the facility tax ID, NPI, contact person, telephone number, extension, fax number, and e-mail address.
3. Complete the patient information section. Enter the 9-digit TRICARE veteran sponsor number, the veteran's name, the patient's name, and their date of birth. Fill in the patient’s address, city, state, and zip code. Specify if another insurance or Medicare will contribute to this service by selecting 'Yes' or 'No' and provide the name of the insurance/benefit if applicable.
4. In the requested service information section, indicate the dates of the 3-day qualifying hospital stay and the last covered day by Medicare or other insurance (Day 100). Provide the start date for TRICARE for Life authorization and include the ICD 10 diagnosis code along with a description of the patient's condition.
5. Refer to the supporting documentation requirements outlined on page 2 and ensure to gather all necessary documents based on the patient's specific needs, such as therapy evaluations, wound assessments, or physician orders.
6. Utilize the completed WI Tricare 31576-097 form as a cover sheet for your submission. Ensure all sections are thoroughly filled out to avoid delays in processing.
7. Finally, review the form for accuracy. Once satisfied, you can save changes, download, print, or share the completed form as needed.

Ensure your skilled nursing facility authorization request is completed online today.