Provider Information
The following sub-sections contain information that is important for providers to acknowledge and follow to provide health care services to TRICARE beneficiaries under the TRICARE program.
Providers must comply with applicable TRICARE requirements. Network providers sign a contract with TriWest to comply with all TRICARE and TriWest rules, requirements, policies, and procedures (please refer to the section on TRICARE Policy Resources). This handbook is not all-inclusive and is intended to present an overview of TRICARE and TriWest policies and procedures. In the event of a conflict between the contract and this handbook, the provisions of the contract supersede the provisions of the handbook.
For current information on TRICARE policy, please refer to the Title 10 of the United States Code, Title 32 of the Code of Federal Regulations (CFR), and TRICARE Manuals: TRICARE Operations Manual (TOM), TRICARE Reimbursement Manual (TRM), and TRICARE Policy Manual (TPM).
Provider Resources
Availity
Availity has a strong national presence connecting two million providers to health plans nationwide. Availity works with other clearinghouses, across other health plans. Availity is accessible through our secure provider portal (specific link to be updated prior to start of health care delivery). Providers who already use Availity can use their existing log-in.
If a provider does not already have Availity, TriWest provides assistance to access this powerful tool. Through Availity, providers can:
- Update provider and office information
- Use the Availity Clinical Gateway Platform to deliver consultation reports and other clinical/medical documentation if they do not already have an existing electronic Health Information Exchange (HIE)
- Access secure transactions, including claims status, authorizations, and pharmacy data
- View communications regarding program updates, new trainings, and updated processes
TriWest has a full training program on Availity that utilizes various training methods that walk providers through our processes and procedures. The training methods include:
- Webinars – live, interactive virtual classes where providers can ask questions in real time
- MicroLearning videos – short, bite-sized video snippets that cover various aspects of TRICARE
- eSeminar Learning Paths – MicroLearnings based on a variety of topics that, when viewed consecutively, form a complete eSeminar; think of MicroLearnings as individual songs and the Learning Path as the playlist
Electronic Health Information Exchange (HIE)
We know many providers have existing HIEs. During credentialing, we confirm that a provider’s HIE is compatible with the HIE the Defense Health Agency (DHA) utilizes.
If a provider does not already have a HIE, we can help them establish one or we can help them get access to Availity, as described in above section, Availity.
Cultural Training
TriWest encourages providers to complete cultural training courses. Providers who furnish proof that they have completed the following courses will receive a “provider readiness designation” in TriWest’s provider directory indicating they have knowledge of military culture and evidence-based treatments:
- “Military Culture: Core Competencies for Healthcare Professionals” course developed by Department of Defense (DOD) and Department of Veterans Affairs (VA)/Veterans Health Administration under the auspices of Integrated Mental Health Strategy
- “Cognitive Processing Therapy for Post-Traumatic Stress Disorder (PTSD) in Veterans and Military Personnel,” “Prolonged Exposure Therapy for PTSD in Veterans and Military Personnel,” and “Depression in Service Members and Veterans in evidence-based treatments” offered by the Center for Deployment Psychology of the Uniformed Services University of the Health Sciences
Links to these trainings are provided in our Availity LMS (specific link to be updated prior to start of health care delivery).
Privacy and Security
TriWest must ensure our providers follow all privacy, security, and telemedicine-specific regulatory, laws, and rules for their profession in both the jurisdiction (site) in which they are practicing as well as the jurisdiction (site) where the beneficiary is receiving care, and compliance, as required, by appropriate regulatory and accrediting agencies. Our credentialing team will monitor provider offices during initial credentialing and thereafter during re-credentialing.
Health Insurance Portability and Accountability Act of 1996
TriWest requires all providers to follow the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA was enacted to:
- Combat fraud, waste, and abuse
- Improve portability of health insurance coverage
- Simplify health care administration
HIPAA requires individual health care providers and institutional providers such as hospitals, their workforce members, and their contractors, to use and disclose Protected Health Information (PHI) only as permitted or required by the HIPAA privacy rule. PHI includes beneficiary-identifiable health details, such as individually identifiable health information.
Military Command Exception
A provider may use and disclose the PHI of individuals who are service members for activities deemed necessary by appropriate military command authorities to ensure the proper execution of the military mission. Exceptions pertaining to disclosures to command authorities of PHI involving service members seeking behavioral health services and substance abuse education services are outlined on the “Military Command Exception” page of the DHA Privacy and Civil Liberties Office website. In the event of a disagreement between a commander and a DOD covered entity (including an affiliated health care provider) concerning disclosure of PHI, the DOD covered entity will, before making its determination, seek the advice of the cognizant legal advisor or command counsel, or the cognizant HIPAA privacy officer, or both, as appropriate. For more information in this area, please refer to Section 4 of Department of Defense Manual 6025.18.
TRICARE Provider Authorization and Certification
TRICARE only reimburses appropriate covered services for eligible beneficiaries provided by TRICARE-authorized providers. TRICARE-authorized providers must comply with all TRICARE requirements, TriWest published policy and procedures, and the TriWest TRICARE Provider Handbook applicable to credentialing.
Providers who are contracted to the network must also be certified in addition to being credentialed. All network providers must accept assignment (i.e., participate). Non-network providers have the option to accept assignment on a case-by-case basis. If a non-network provider accepts assignment, they are recognized as a participating non-network provider, committing to accepting the TRICARE-allowable charge as complete payment for covered services and filing claims for TRICARE beneficiaries. When a beneficiary files a claim for services rendered by a non-participating individual professional provider who is legally practicing and eligible for TRICARE authorization, the provider will be certified, and payment will be issued to the beneficiary.
Providers can access certification forms necessary for providers to become TRICARE-authorized online (specific link to be updated prior to start of health care delivery).
Non-participating providers do not have to accept the TRICARE-allowable charge or file claims for beneficiaries. By federal law, if a non-network provider does not participate on a particular claim, the provider may not charge more than 15% above the TRICARE-allowable charge (115%).
National Provider Identifiers (NPI)
TRICARE providers should already have NPIs. If a provider does not have an NPI, they can complete the online NPPES application or download the National Provider Identifier Application/Update Form. Providers can find more information at CMS.gov.
TRICARE Credentialing
To join the TRICARE West Region network, a TRICARE-authorized provider, if not already credentialed with us, must complete the credentialing process and sign a contract with TriWest. Please note that all network providers must be Medicare participating providers. (Refer to TRICARE Policy Manual Chapter 11, Section 1.2 for more information. The credentialing process requires verification of the provider’s education, board certification, license, professional background, malpractice history, and other pertinent data. A fully executed copy of the contract is forwarded by TriWest to the provider. Please note that credentialing approval is sent separately from the fully executed contract.
Providers must have a signed contract with TriWest and have received credentialing approval from TriWest to be considered a network provider. TriWest monitors each network provider’s quality of care and adherence to DOD, TRICARE, and TriWest policies. Network providers must be re-credentialed every three years.
TriWest does not credential VA Community Care Network providers for TRICARE.
Providers must meet VA-specific requirements as specified within the TRICARE Policy Manual, Chapter 11.
Individual Providers
To meet the minimum credentialing criteria established by TriWest, individuals must have:
- Completed education and training required for the applicable specialty
- A current, active and unrestricted license
- An unrestricted and active Drug Enforcement Agency registration, as applicable to their license
- An unrestricted and active controlled substance registration, as applicable to their license per their state requirements
- Adequate malpractice or liability insurance per local requirements
- Further providers cannot participate if they:
- Are barred from participating in federal programs
- Have a felony conviction
- Have a physical or mental condition that would unreasonably limit their ability to render high quality care
- Have a substance dependency that is untreated or unmanaged
- Have gaps in work history of more than six months
Provider types that can participate subject to credentialing requirements are specified in TRICARE Policy Manual, Chapter 11.
Institutional Providers
In order to participate, facilities must have:
- An active and unrestricted license
- Liability insurance that is active and adequate per state or locality requirements
- Proper accreditation as applicable for the facility type
- Facilities cannot participate if they are barred from participating in federal programs
For more information about becoming a network provider, visit TriWest’s Join Our Network page. Providers can check credentialing status online (specific link to be updated prior to start of health care delivery).
Delegated Credentialing
If the provider group has a delegated credentialing agreement (Delegation Agreement) with TriWest, please email TriWest (specific email to be updated prior to start of health care delivery) for additional instructions.
Charging Administrative Fees
Providers may not charge TRICARE beneficiaries administrative fees. Per the TRICARE Reimbursement Manual, Chapter 1, Section 19, providers may incur administrative expenses during the course of doing business. Most of these expenses are normal and payment for them is included in the payments made for the medical services rendered by the provider. Others are not covered because they are not medical services related to the treatment of an illness or injury. In either case, separate charges for administrative expenses are not allowed. Such expenses include:
- Penalty or interest charges imposed on a beneficiary by a provider because of failure to make timely payment on a bill are not covered.
- Provider administrative expenses such as charges for claims completion and furnishing medical records are not separately allowable.
Nondiscrimination policy
All TRICARE-authorized providers agree not to discriminate against any TRICARE beneficiary on the basis of race, color, national origin, or any other basis recognized in applicable laws or regulations. To access the full TRICARE policy, refer to the TRICARE Operations Manual Chapter 1, Section 5.
Office and Appointment Access Standards
TRICARE access standards are designed to ensure that beneficiaries receive timely health care services conveniently located within a reasonable distance from their homes. Network providers must adhere to the following appointment access standards:
- Preventive care appointment – Four weeks (28 days)
- Routine care appointment – One week (7 days)
- Specialty care appointment – Four weeks (28 days)
- Urgent care – One day (24 hours)
- Emergency care – Emergency services shall be available and accessible to handle emergencies within the service area 24 hours a day, seven days a week
Specialty Care Responsibilities
Pre-authorization for certain specialty care services is required. TRICARE Prime beneficiaries seeking specialty care require a referral from their PCM. PCMs and/or specialty care providers must coordinate with TriWest to obtain referrals and pre-authorizations. Please see the Primary Care Managers section for more information.
TRM, Chapter 1, Section 28, Paragraph 2.0 states that in the case of a provider’s failure to obtain a required preauthorization, the provider’s payment shall be reduced by 10% of the amount otherwise allowable. Under the managed care contracts, a network provider’s payment can be subject to a greater than 10% reduction or a denial if the network provider has agreed to such a reduction or denial in the contract. These payment reduction penalties cannot be passed onto the beneficiary for payment. It is the provider’s responsibility to obtain pre-authorization when required.
Network behavioral health care providers can refer beneficiaries for behavioral health care in lieu of the PCM. ADSMs may require pre-authorization from the MTF.
Specialty referral requirements vary by TRICARE beneficiary type and program option:
- TRICARE Prime:
- ADSMs: All civilian specialty care requires a referral from a beneficiary’s PCM and/or TriWest. In addition, pre-authorization from TriWest is required for certain services
- Active Duty Family Members (ADFM): Referrals to specialty care are required with the following exceptions:
- Preventive care services from network providers
- Urgent care services from network providers
- Behavioral health care outpatient visits for medically necessary treatment for covered conditions
- When using the POS option
Pre-authorization from TriWest is required for certain services
- TRICARE Select: Referrals are not required to TRICARE-authorized specialty care providers
- Pre-authorization from TriWest is required for certain services
- Providers can use the TriWest online Referral and Authorization Decision Support (RADS) tool to determine if an approval from TriWest is required (specific link to be updated prior to start of health care delivery)
Providers should submit referrals and pre-authorizations via the online provider submission tool, CareAffiliate, online (specific link to be updated prior to start of health care delivery).
Any specialty care outside of the indicated referral scope requires an authorization request or communication back to the beneficiary’s PCM for necessary referrals.
Opioid Safety Initiative (OSI)
The Defense Health Agency (DHA) of the Department of Defense (DOD) and the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) developed and implemented the Opioid Safety Initiative (OSI) to improve quality of life, reduce suffering from chronic pain, decrease opioid prescribing practices associated with complications, and promote safer opioid-related prescribing for active duty Service members (ADSM), Veterans and their families.
The OSI addresses the challenges of opioid dependency and closely monitors DOD and VA dispensing practices system-wide, including care that occurs in the community. It coordinates pain management through patient and provider education, enhanced testing and safety monitoring, thoughtful tapering plans, the use of complementary integrated health modalities (i.e., acupuncture, massage therapy, yoga, etc.) and cognitive behavioral therapy for pain.
The current OSI guidance provides prescribers a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are being considered for or are currently on long-term opioid therapy. Recommended actions for providers to take include:
- Perform a thorough assessment including all prior treatment approaches
- Set realistic expectations for pain management early and review often
- Request non-pharmacological/non-opioid treatment options when appropriate
- Proceed with opioid treatment with caution, as briefly as possible with the lowest dose immediate release option (not PRN long acting formulations)
- Reassess progress and safety at every visit. For example, drug screening or confirmation at least every six months, naloxone available, secure storage to protect others, consistently verify the state Prescription Drug Monitoring Program (PDMP) also known as Prescription Monitoring Programs – prior to prescribing any controlled substance each and every time a prescription is written, etc.
- Stop and reassess if concerns begin to occur
- Submit requests for substance abuse treatment when needed
Medical Documentation: Clear and Legible Reports (CLR)
Providers should return Clear and Legible Reports (CLR) for services rendered to active duty service members (ADSM) and military treatment facilities (MTF) Prime beneficiaries. CLRs should be returned to the military hospital or clinic within 10 business days from the date of service for outpatient care. Inpatient discharge CLRs are due within 40 business days of discharge.
Outpatient CLRs should contain applicable information about the care provided such as:
- Specialty evaluations
- Lab and radiology reports
- Preventive services
- Clinical procedures
- Ancillary care
- Other clinical information obtained during the service
Inpatient CLRs should include:
- Consultation reports
- Operative reports
- Discharge summaries
Providers must follow the CLR instructions included on the referral/authorization confirmation from TriWest. Providers may submit CLRs using Health Information Exchange (HIE) networks that are connected to the Government’s electronic health record system. If a provider does not have access to an HIE, they may submit CLRs online (specific link to be updated prior to start of healthcare delivery).
Updating Provider Information
Based on their contract with TriWest, network providers are required to notify TriWest or their designated network subcontractor of any change in address, professional affiliation, tax identification number (TIN), or licensure status. TriWest often partners with a network subcontractor (e.g., Blue Cross Blue Shield plans) to develop and manage the provider network. Our provider contracts specify the designated network subcontractors that manage provider data, credentialing, and other functions as designated by TriWest. Some provider contracts may not have a designated network subcontractor. In such cases, providers should provide the updated information directly to TriWest.
Providers should use their best efforts to notify TriWest or their designated network subcontractor at least 60 days prior to the date of the change, or at the earliest opportunity if such prior notice is impracticable. If advance notification is not possible, providers should notify TriWest or their network subcontractor no later than 10 business days after the effective date of the change.
Prompt notification to TriWest or their designated network subcontractor of changes in information allows beneficiaries seeking health care services and providers seeking to refer care to access the most accurate provider information. Additionally, it allows TriWest to send payments to the correct address and avoids PHI disclosures.
The Network Provider Directory, located at www.triwest.com (specific link to be updated prior to start of health care delivery), helps beneficiaries and other providers locate TRICARE network providers. To confirm the accuracy of individual listings and information, network providers must visit the online Network Provider Directory at www.triwest.com (specific link to be updated prior to start of health care delivery). To update demographic information, use Availity or submit a TRICARE Provider Roster at www.triwest.com (specific links to be updated prior to start of health care delivery).
If you are a network provider and do not see your practice listed in the Network Provider Directory, contact the TriWest Customer Service line or email TriWest (specific phone number and email to be updated prior to start of health care delivery) to inquire about being listed. Providers interested in joining the TriWest network should go to JoinOurNetwork.TriWest.com.
For groups that have a delegated credentialing agreement, please see the Delegated Credentialing information above, TRICARE Credentialing.
Non-network providers are not included in the Network Provider Directory. Doctors, hospitals, and other health care professionals who are TRICARE authorized and have submitted a claim over the past 14 months can be found on the online Non-Network Provider Directory. To update and verify demographic information, please visit www.triwest.com or by fax updated information to TriWest (specific link and fax number to be updated prior to health care delivery).
DRAFT — pending DHA approval. Submitted for review on 2/15/24.