Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Created 06/17/08

ST2

TRICARE STATEMENT EXAMPLES

Example 1: Palmetto Government Benefits Administrators

If information
appears here the
“Provider Accepted
Assignment”.
Total
Charge

Medicare
Payment

Medicare
Approved
Amount

Created 12/30/05

ST2

TRICARE STATEMENT EXAMPLES
(continued)
Example 2: TRICARE Southwest

Medicare
Approved
Amount

Medicare
Payment

Example 3: WPS TRICARE Administration

Total
Charge

Total
Charge
Medicare
Approved
Amount

Medicare
Payment