TriCare West: Palmetto GBA
Please follow the Enrollment Instructions below to become an electronic submitter to Palmetto GBA for your Tricare West claims.
Please Note: this is only for claims that need to be sent to Payer ID 99726. For TriCare West claim submission, which is Payer ID TWVACCN, please review the instructions found on this page instead: SolAce - Electronic Medical Claims - TriWest VACCN Regions 4 & 5 Palmetto GBA (solace-emc.com)
The following documents are required enrollment documents that must be completed, signed and returned to the PGBA office prior to initiation of electronic claims submission or inquiry.
1. Clearinghouse/Direct Submitter Trading Partner Agreement (Fill out this form if you will be sending claims directly to Tricare)
2. HIPAA EDI Provider Agreement (Fill out this form if you will be sending Tricare claims through a clearinghouse or billing service)
If the above links do not work properly, download the forms listed above from here:
http://www.mytricare.com/internet/tric/tri/mtc_nprov.nsf/sectionmap/Elct...
3. EDIG Trading Partner Enrollment Form
If the above link does not work properly, download the form listed above from here:
http://204.28.103.156/enrollmentandagreements/hospitalandphysiciantradin...
If the above link does not work properly, download the form listed above from here:
http://www.mytricare.com/internet/tric/tri/mtc_nprov.nsf/sectionmap/Frms...
5. SFTP-VPN Customer Connectivity Parameter Survey
If the above link does not work properly, download the form listed above from here:
https://www.tricare-west.com/content/hnfs/home/tw/prov/res/provider_forms/edi.html
If you have any questions regarding any of the documents in this package, please phone the PGBA EDI Technology Support Center at 1-800-259-0264.
We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.
Our Vendor Information
| Vendor Name - AXIOM Systems, Inc. |
| Contact - EDI Team |
| Vendor Code - N/A |
| Phone - 602-439-2525 |
| Fax - 602-439-0808 |
| Address - 241 East 4th Street, Suite 200 Frederick, MD 21701 |
| Software Name - SolAce EMC |
| E-mail - Support@SolAce-emc.com |
Clearinghouse/Direct Submitter Trading Partner Agreement
Fill out this form if you will be submitting your claims directly to Tricare
- Please leave the Agreement Number line blank
- Enter today’s date and your Business/Practice or Provider name in the first paragraph (You are the Trading Partner)
- Please complete section 9.1 on page 13 with your information (This tells PGBA who they should send notices to)
- Complete the Trading Partner section on the left side of page 16
- Complete Exhibit A
- Enter your information in the Trading Partner section
- Enter the software vendor information provided above in the Vendor information table. For AXIOM’s Tax ID please call us at 602-439-2525
- If you are a provider using a Billing Service, please enter the Billing Services information in the Billing Service Information section
- On Exhibit A Page 2 Please Write in under Means of Electronic Access " Secure FTP" and "Will use AXIOM Systems Inc's IP and Certificate"
HIPAA EDI Provider Agreement
(To be completed only by provider’s who will be billing via a Billing Service)
Billing Services: Your providers must fill out this form to authorize you to submit their Tricare Billings.
Providers with a Billing Service please sign and date Section C of this form
- For Contact Name, please enter the name of the main contact person for your office
- For Billing Service Name/ Vendor, please enter your billing services information
- On the last page of this form, please list your Tricare Number, Name, and Demographic information
EDIG Trading Partner Enrollment Form
- Enter today’s date
- New applicants, please select “New Trading Partner ID”
- Complete the Trading Partner Name field with your Business/Practice or Provider name
- Leave the Trading Partner ID line blank if you are applying for a new ID and fill in your Tax ID in the Tax ID line
- For Type of Business select either Institutional or Professional
- If you are a Billing Service, please choose Billing Service
- For Line of Business, please choose “PGBA LLC”
- Enter today’s date for the start date and leave the end date blank
- Compression: choose PKZIP
- Protocol: choose Secure FTP ( on the right in the blank area write in "will use AXIOM Systems Inc's IP and Certificate" )
- Complete your address and contact information.
- For Transactions, choose:
- ASC X12N 835 for Electronic Remits (EOB's)
- ASC X12N 837I for Institutional, or
- ASC X12N 837P for Professional
- For every transaction checked, provide an average number of transactions submitted weekly
- For Vendor’s information enter: AXIOM Systems, Inc.
- Address: 241 East 4th Street, Suite 200 Frederick, MD 21701
- Transactions: 837P-5010 (for professional claims) and/or 837I-5010 (for institutional claims)
- Complete the Customers Information section with your information
- Leave the last page blank
SFTP/VPN Customer Connectivity Parameter Survey
- Enter your information in the first section
- Business Contact Name, Phone and Email
- Technical Contact Name, Phone and Email
- Company Name, Phone and Address
- Please leave the entire VPN Section Blank
- On the SFTP Side please enter:
- "Use Axiom's IP Address"
- For Customer FTP Client Software enter "Use Axiom's SSH Key"
ERA Enrollment Form
Note: Do not send this in with your enrollment packet. You must wait for your Submitter ID to be assigned prior to completing this form.
- Please enter your Provider name and address
- Please enter your Tax ID and NPI
- Enter your Tricare Provider Number and your assigned Tricare Submitter ID
- List your Tricare Provider Numbers, NPI's and name
- Enter your Provider contact information
- Please enter either your Tax ID or NPI
- In the box next to "Method of Retrieval" please type in "Direct"
- Leave the Clearinghouse section blank
- Check the box for "New Enrollment"
- Please sign, enter your title, and today's date for both Submission Date and Requested ERA Effective Date
Submitting your Forms
It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to the following addresses:
Send the Electronic Provider Trading Partner Agreements and EDIG Trading Partner Enrollment to:
Palmetto GBA, EDIG OperationsPO Box 17151 Augusta, GA 30903
Send All ERA Enrollments and HIPAA EDI Provider Agreement form (if using Billing Service)
to:
TRICARE PGBA, LLC
TRICARE Electronic Data Interchange
PO Box 202007
Florence, SC 29502-2007
It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.
Waiting for a Response
Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)
After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the PGBA, LLC EDI Technology Support Center at 1-800-259-0264.
Testing
Once you have received your Submitter ID and Password from PGBA, LLC, please call the SolAce Support Team at 602-439-2525 and set an appointment for a Mailbox setup and Test Transmission.
Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.
customer Testimonial
From our customers
I am very pleased with our SolAce billing software and how easy it is to navigate. They have a great team who can train you to do billing even if you don’t have billing experience. Special thanks to Cathy, Gigi, and Skyler who always helps me out every time I have issues.
SolAce is awesome software. I absolutely LOVE it. For over three years I have used this software daily for multiple long term care facilities to submit claims to various MACs, Medicaid, and Medicare Advantage and Supplemental Insurance carriers. It is convenient, simple to use and far less costly than any Clearing House software I had explored. The ability to import from my Practice Management Software and Therapy Providers has reduced any RTP claims edits and denials are a thing of the past. Customer Support is “Johnny on the spot”, but terrific as they may be, it gets better - RARELY do I need to call. LOVE IT, LOVE IT, AND LOVE IT.
I think our medical office was one of the first to use SolAce in the mid 1990’s and we are still using it today for all of our electronic billing because it works ! It was simple for our staff to learn and it integrated easily with our accounting/billing program. It has been especially nice to know that the Axiom staff is there when Medicare changes something and they are right on it. They made the 5010 change a simple process plus made educational seminars available to us. Thank you to all the Axiom/ Ivertex professionals who have helped us for the last 15+ years.
SolAce has been a valuable tool that has been a life saver for my billing service for years. It has allowed me to bill professional and institutional claims with ease. Customer service @ SolAce is top rated in my opinion. The SolAce product is very user friendly and affordable. Thank you SolAce team for a great product.
Easy to use, Customer support has always been excellent, Thanks SolAce Team.
I am a new client and was having a tough time getting everything set up just right. I had to make calls to CEDI and when I called back the rep I spoke with prior even helped the 2nd rep to make sure I got all the info I needed. They definitely work as a team. Within a short period of time they had my system up and running. I never could've done it without them.
Awesome customer service every time!
I can't tell you how wonderful it is to work with your agency. They are courteous, knowledgeable,friendly, and a joy to work with - I can't say enough. Thank you!!
The service was very good. Phone answered promptly even though it was around 6 p.m. my time. Very courteous and helpful. So far I have had really good experiences with your support team.
The follow-up is outstanding - whenever there is an issue I am contacted to be sure that all is working well and to my satisfaction.
Everyone in your company is very helpful and pleasant, and they always have the quickest response time on fixing the situation.
Tech was very helpful, very patient and very professional. She knew of the issue quickly and stayed at hand until issue was resolved. Very satisifed with the service.
