TRICARE Medical Coverage

Preventive Care

Preventive Care services include diagnostic and other medical procedures not related directly to a specific illness, injury, or definitive set of symptoms, or obstetrical care, but rather performed as periodic health screening, health assessment, or health maintenance. Covered preventive care services are applicable to beneficiaries 6 years of age or older.

Per TRICARE Policy Manual Chapter 7, Section 2.2, TRICARE Prime enrollees may receive Prime clinical preventive services from any network provider within their geographic area of enrollment without referral or authorization. If a TRICARE Prime clinical preventive service is not available from a network provider (e.g., a network provider is not available within prescribed access parameters), an enrollee may receive the service from a non-network provider with a referral from the PCM and authorization from the TriWest.

Covered Preventive Care services include, but are not limited to:

• Cancer screening examinations and services
• Immunizations
• Health promotion and disease prevention (HP&DP) examinations
• Well Woman examinations
• Routine eye examinations
• Audiology screening

For more information, please refer to the TRICARE Policy Manual Chapter 7 Section 2.1 and TRICARE Policy Manual Chapter 7 Section 2.2.

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Behavioral Health

TRICARE covers services delivered by qualified, TRICARE-authorized behavioral health care providers practicing within the scope of their licenses, to diagnose and/or treat covered behavioral health disorders.

Only the types of providers listed in TOM Chapter 7, Section 3.7 are considered qualified providers of behavioral health services. All services and supplies provided by unauthorized providers or not considered medically or psychologically necessary are generally excluded. For information about the requirements for being a TRICARE-authorized provider, refer to the TRICARE Policy Manual, Chapter 11, Sections: 3.6-3.11.

According to TOM Chapter 7, Section 3.7 covered conditions must:

• Involve a clinically significant behavioral or psychological syndrome or pattern that is associated with a painful symptom, such as distress, and that impairs a patient’s ability to function in one or more major life activities.
• The condition must be one of those conditions listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

To determine if a specific service is a covered benefit or if coverage is limited, use the Referral and Authorization Decision Support (RADS) tool (specific link to be updated prior to start of health care delivery).

Incident Reporting

All serious occurrences involving a TRICARE beneficiary while receiving services at a TRICARE-authorized treatment program (e.g., RTC, freestanding PHP, or SUDRF) must be reported to TriWest by phone (specific phone number to be updated prior to start of health care delivery) or faxing the report (specific fax number to be updated prior to start of health care delivery) within one business day.

Pre-Authorization and Referral Requirements

TRICARE pre-authorization and referral requirements vary according to beneficiary type, program option, diagnosis, and type of care. See the Referral and Authorization Decision Support (RADS) tool or Prior Authorization List (PAL) (specific link to be updated prior to start of health care delivery).

Clinical Documentation for Behavioral Health Care Services

TRICARE providers must keep sufficient clinical records to substantiate that care provided was actually and appropriately furnished and medically or psychologically necessary.

Behavioral health care provider types must, at a minimum, maintain medical records in accordance with TJC, CARF, CoA or an accrediting organization approved by the Director, DHA.

Acceptable clinical documentation may include, but is not limited to:

• Psychiatric and psychological evaluations
• Physician orders
• Treatment plans
• Physician and/or integrated progress notes
• Discharge summaries

Standardized Measures

All behavioral health care settings must include assessments using the following standardized measures in the evaluation report for the following diagnosis:

• Post-Traumatic Stress Disorder (PTSD): PTSD Checklist (PCL-5)
• Generalized Anxiety Disorder (GAD): GAD-7
• Major Depressive Disorder (MDD): Patient Health Questionnaire 9 (PHQ-9)

According to TPM Chapter 11, Section 12.3 Providers must notify the referring MTF when a TRICARE beneficiary in the provider’s clinical judgment, meets any of the following criteria:

• Is a potential harm to self – The provider believes there is a serious risk of self-harm by the Service member either as a result of the condition itself or medical treatment of the condition
• Is a potential harm to others – There is a serious risk of harm to others either as a result of the condition itself or medical treatment of the condition
• Is a potential harm to mission – There is a serious risk of harm to a specific military operational mission. Such a serious risk may include disorders that significantly impact impulsivity, insight, reliability, and judgment
• Is admitted or being discharged from any inpatient behavioral health or Substance Use Disorder Rehabilitation Facilities (SUDRF)
• Is experiencing an acute medical condition or engaged in an acute medical treatment regimen that impairs the beneficiary’s ability to perform assigned duties
• Has entered or is being discharged from a Substance Use Disorder (SUD) program

Non-Covered Conditions and Treatment

A complete list of behavioral health care services that are excluded under TRICARE are provided on the TRICARE Mental Health Exclusions webpage. Before delivering care, network providers must notify TRICARE beneficiaries if services are not covered. The beneficiary must agree in advance in writing to receive and accept financial responsibility for non-covered services by signing the Request for Non-Covered Services waiver (specific link to be updated prior to start of health care delivery).

To obtain specific information on TRICARE policy, benefits and coverage, please consult the TRICARE Policy Manual, TRICARE Reimbursement Manual, or the code look-up feature on the Referral and Authorization Decision Support (RADS) tool (specific link to be updated prior to start of health care delivery).

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Telemedicine

TRICARE covers telemedicine visits including secure video conferencing and audio-only (using a computer or a smartphone) through a secure connection with a beneficiary’s provider. Beneficiaries pay cost-shares and copayments for telemedicine visits. TRICARE covers the following telemedicine visits:

• Office visits
• Preventive health screenings
• Telemental health services
  • A referral for telemental health services is required, more information can be found on the Telemental Health Services webpage

Beneficiaries can contact TriWest (specific phone number to be updated prior to start of health care delivery) for a referral or pre-authorization for telemedicine visits, including telemental health services.

Audio-only telemedicine for TRICARE for Life beneficiaries should be covered by Medicare. If not, TRICARE for Life is the first payer. Refer to https://www.medicare.gov/ for information on Medicare coverage.

Refer to the Telemedicine webpage and TRICARE Policy Manual (TPM), Chapter 7, Section 22.1 for more information on TRICARE’s telemedicine benefit.

Originating Sites

TriWest monitors originating site location coverage across the TRICARE West Region. Originating site coverage is assessed through evaluation of our provider partners against Health Professional Shortage Areas (HPSA) and examination of provider locations submitting claims with the originating site CPT code (i.e., Q3014). This allows TriWest to determine where originating site location gaps exist so we can develop targets to expand access.        

Provider Requirements

TriWest ensures providers follow all telemedicine-specific regulatory, licensing, credentialing and privileging, malpractice/insurance laws, and compliance with required regulatory and accrediting agencies, in accordance with the TRICARE Policy Manual, Chapter 7, Section 22.1. Providers must:

• Follow professional discipline and national practice guidelines when practicing via telemedicine, and any modifications to applicable clinical practice guidelines for the telemedicine setting shall ensure that clinical requirements specific to the discipline are maintained
• Make arrangements for handling emergency situations at the outset of treatment to ensure consistency with established local procedures
  • In particular, for behavioral health services, this should include processes for hospitalization or civil commitment within the jurisdiction where the patient is located if necessary
• Implement means for verification of provider and patient identity for synchronous telemedicine services
  • For telemedicine services where the originating site is an authorized institutional provider, the verification of both professional and patient identity may occur at the host facility
  • For telemedicine services where the originating site does not have an immediately available health professional (e.g., the patient’s home), the telemedicine provider provides the patient (or legal representative) with the provider’s qualifications, licensure information, and, when applicable, registration number (e.g., National Provider Identifier) and the patient provides two-factor authentication
• Document provider and patient location in the medical record as required for the appropriate payment of services for synchronous telemedicine services
  • Documentation includes elements such as city/town, state, and ZIP code (or country for overseas services)
• Ensure that transmission and storage of data associated with asynchronous telemedicine services is conducted over a secure network and is compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements
• Establish an alternate plan for communicating with the patient (e.g., telephone) in the event of a technological breakdown/failure
  • This should be developed at the outset of treatment. In order for the telemedicine services to resume, all technological requirements of this policy must be restored, as telemedicine cannot be performed by telephone services alone.
• Apply HIPAA privacy and security requirements for the use and disclosure of Protected Health Information (PHI) to all telemedicine services

Reimbursement for Telemedicine – Distant Site

For TRICARE payment to be authorized, the provider must be a TRICARE authorized provider and the service must be within a provider’s scope of practice under all applicable state(s) law(s) in which services are provided and or received. Telemedicine services are subject to the same authorization/referral requirements. Beneficiaries can contact TriWest (specific phone number to be updated prior to start of health care delivery) for a referral or pre-authorization for telemedicine visits, including telemental health services.

Beneficiaries are responsible for any applicable copay or cost-share.

For technical requirements, connectivity, privacy and security, and other issues, refer to the TRICARE Policy Manual, Chapter 7, Section 22.1.

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Urgent Care

TRICARE covers urgent care for medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately but does require attention before it becomes a serious risk to health.

Examples of serious conditions (but not life-threatening) that should receive urgent treatment include sprains, scrapes, ear aches, sore throats, and a raised temperature.

Urgent Care for TRICARE PRIME – Active Duty Service Members

According to the TRICARE Operations Manual, Chapter 7, Section 5, Paragraph 2.1, active duty service members (ADSM) enrolled in TRICARE Prime require a referral from the MTF provider or through the MHS Nurse Advice Line (NAL). ADSMs enrolled to the TRICARE Overseas Program (TOP) or in TRICARE Prime Remote (TPR) do not need an urgent care referral, but they are still held to applicable DOD and Service requirements concerning authorization for private sector care.

TRICARE Prime’s Point of Service (POS) option does not apply to ADSMs, who may be responsible for the entire cost of their care if they seek urgent care without a referral when required.

Urgent Care for Other Beneficiaries

The following beneficiaries do not require a referral or authorization prior to seeking any urgent care services from a network or non-network provider, in accordance with TRICARE Operations Manual, Chapter 7, Section 5.0; however, out-of-pocket costs may be more when seeking services from non-network providers:

• TRICARE Select
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Young Adult (Prime and Select)

These beneficiaries may self-refer for urgent care from a TRICARE network provider or a TRICARE-authorized (network or non-network) Urgent Care Center (UCC) or Convenience Clinic (CC). If the enrollee seeks care from a non-network provider, the usual POS deductible and cost-shares shall apply.  

Nurse Advice Line

Beneficiaries may contact the Nurse Advice Line 24 hours a day, seven days a week, 365 days per year at 1-800-TRICARE (874-2273). Registered Nurses are available to help beneficiaries:

• Answer urgent care questions
• Give health care advice
• Help find a doctor
• Schedule next-day appointments at military hospitals and clinics

All TRICARE beneficiaries can access the Nurse Advise Line in the U.S. except those enrolled in the US Family Health Plan (USFHP). Beneficiaries who live overseas can call the Nurse Advice Line when traveling in the U.S., but must coordinate care with their Overseas Regional Call Center.

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Hospitalization

TRICARE covers hospitalization services, including:

• Emergency services
  • Medical or psychiatric emergency
  • Immediate hospital admission
  • Mental health or Substance Use Disorder (SUD) services include:
    • Management of withdrawal symptoms (detoxification)
    • Stabilization
    • Medical complications from the disorder
  • Non-emergency services
    • Inpatient psychiatric hospitalization
      • Diagnosis and treatment of mental health
      • SUD

All scheduled hospitalizations require pre-authorization. For non-emergency inpatient psychiatric services, care may be provided in private psychiatric hospitals or local, state, or federal government psychiatric hospitals.

Inpatient psychiatric services may receive an approval if the beneficiary:

• Poses a serious risk of harm to themselves or others
• Needs specialized medication
• Needs psychological treatment
• Has a significant impairment in functioning
• Needs to be in a hospital full-time
• Is unable to maintain themselves in the community with only outpatient services

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Hospice Care

Beneficiaries may receive hospice care if they are terminally ill. Hospice care helps manage beneficiaries’ pain and symptoms, while helping them live as comfortable as possible. The benefit covers supportive services including pain control and counseling services, home health aide services, and personal comfort items.

Hospice care services require: 

• A beneficiary to be referred for hospice care
• A beneficiary’s doctor to submit orders for hospice care
• A beneficiary to complete and give an election statement to a hospice provider
  • The provider must file the election statement with TriWest

Beneficiaries who receive care under hospice cannot receive curative treatment related to the terminal illness unless hospice has been revoked. Beneficiaries under age 21 are eligible for medically necessary curative treatment related to the illness in addition to palliative care.

TRICARE provides hospice care in three benefit periods:

• Period one: 90 days
• Period two: 90 days
• Period three:Unlimited 60-day periods

Beneficiaries need pre-authorization for each period and each 60-day period requires recertification of terminal illness.

Hospice levels of care include continuous home care, general hospice inpatient care, inpatient respite care, and routine home care. Types of care may include:

• Physician services
• Nursing care
• Counseling
• Medical equipment and supplies
• Medications
• Medical social services
• Physical and occupational services
• Short-term inpatient care
• Speech and language pathology

Hospice care requires pre-authorization from TriWest for all beneficiaries.

For more information about TRICARE’s hospice coverage, refer to TRICARE Reimbursement Manual, Chapter 11, Section 3.

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Durable Medical Equipment (DME)

TRICARE covers Durable Medical Equipment (DME) or DME Prosthetics, Orthotics, and Supplies (DMEPOS) when prescribed by a physician that:

• Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition
• Maximizes the patient’s function consistent with the patient’s physiological or medical needs
• Provides the medically appropriate level of performance and quality for the medical condition present
• Is not otherwise excluded by the regulation and policy

If DME needs customization or repairs, TRICARE covers the following situations:

• Medically necessary customization or attachments to the DME to accommodate the medical disability, when the physician has prescribed the equipment as medically necessary and appropriate
• Medically necessary covered accessories and attachments to a DME necessary to make the DME “serviceable” for a particular disability (e.g., a car lift that is an accessory to a wheelchair)
• Repairs to equipment that a beneficiary owns when needed to make the item serviceable
• Replacement of DME that a beneficiary owns when:
  • There is a change in the beneficiary’s physical condition
  • There is accidental damage to the DME
  • The DME is inoperative and cannot be repaired
  • The U.S. Food and Drug Administration has declared the DME adulterated
• Duplicate items (those that serve the same purpose, but may not be an exact duplicate, such as a portable oxygen concentrator as a backup for a stationary oxygen generator) that are essential to provide a fail-safe, in-home, life-support system

Items that are not covered under the TRICARE benefit include:

• DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of DME item to its patients at no additional charge in the usual course of providing its services is excluded
• DME available to the beneficiary from a military hospital or clinic
• DME with deluxe, luxury, or immaterial features, which increase the cost of the item to the government relative to a similar item without those features
• Routine periodic servicing, such as testing, cleaning, regulating, and checking, which the manufacturer does not require be performed by an authorized technician
• Duplicate items of otherwise allowable DME to be used solely as a back-up to currently owned or rented equipment
• Expendable items such as incontinent pads, diapers, ace bandages, etc.
• Non-medical equipment (e.g., humidifier, electric air cleaners, safety grab bars, etc.)

For more information, please reference TRICARE Policy Manual, Chapter 8, Section 2.1 and  TRM Chapter 1, Section 11.

Upgraded DMEPOS (Deluxe, Luxury, and Immaterial Features)

An upgraded item of DE, which otherwise meets the DE benefit requirement and is medically necessary, is covered if the prescription specifically states the medical reason why an upgrade is necessary. If the beneficiary prefers to upgrade an item of DE, which otherwise meets the DE benefit requirements, the beneficiary will be solely responsible for the cost that exceeds the cost of what the Government would pay for the standard equipment. Refer to the TRICARE Policy Manual, Chapter 8, Section 2.1 and TRICARE Reimbursement Manual Chapter 1, Section 11 for more information.

DMEPOS Referral and Authorization Guidelines

Providers can use the TriWest Referral and Authorization Decision Support (RADS) tool to look up codes to determine if a specific DME/DMEPOS is covered or if a referral or authorization is required (specific link to be updated prior to start of health care delivery).

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