TRICARE Provider Types
TRICARE defines a provider as a person, business, or institution that provides health care. Beneficiaries must use TRICARE-authorized providers that are licensed by a state, accredited by a national organization, or meet other standards of the medical community. For more information on provider types, refer to chart of provider types at https://www.tricare.mil/. TriWest contracts with network providers in the West Region to deliver health care to TRICARE beneficiaries.
TRICARE Authorized Providers
Sec. 199.6 of the Title 32 National Defense Manual describes requirements for TRICARE providers and suppliers. TRICARE-authorized providers are those that meet state licensing and certification requirements and are authorized by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, urgent care centers, ancillary providers (nurse practitioners, physician assistants, and physical therapists), laboratory and radiology providers, and pharmacies.
TRICARE-authorized providers do not include any provider type not specifically named in TPM, Chapter 11. For providers in TriWest's Community Care Network (CCN) provider network for the U.S. Department of Veterans Affairs, please note that there are differences between the contracts. Beneficiaries are responsible for the full cost of care if they see providers who are not TRICARE-authorized.
Primary Care Managers
In TRICARE Prime, Primary Care Managers (PCM) coordinate care for beneficiaries assigned as their patients and provide all non-emergency care within their capabilities. PCMs are responsible for maintaining beneficiary medical records and referring beneficiaries for urgent, emergent, and specialty care outside of their capabilities. This includes working with TriWest to obtain referrals and prior authorizations.
PCMs can be a part of a Military Treatment Facility (MTF) or a civilian network provider. The following provider specialties are eligible to serve as PCMs in TRICARE:
- General practice
- Family practice
- Internal medicine
- Pediatrician
- Obstetrician/gynecologist
- Physician assistant
- Nurse practitioner
- Certified nurse midwife
PCMs are selected by TRICARE Prime beneficiaries at the time of enrollment. TRICARE Prime beneficiaries must seek all non-emergency services from their PCM and obtain referrals to other providers prior to obtaining services.
PCMs are responsible for:
- Primary care services
- Following TRICARE procedures for obtaining necessary prior authorizations and referrals for non-emergency care
- Providing access to care 24 hours a day, seven days a week (including after-hours and urgent care services) or arrange for on-call coverage by another PCM
- Maintaining beneficiary medical records, including from referrals and emergency care
Behavioral Health Providers
The TRICARE behavioral health care outpatient network consists of TRICARE-authorized providers, such as:
- Psychiatrists and other physicians
- Clinical psychologists
- Certified psychiatric nurse specialists (CPNS)
- Certified clinical social workers
- TRICARE-certified mental health counselors (TCMHC)
- Certified marriage and family therapists
- Supervised licensed pastoral counselors
- Supervised behavioral health counselors
- Licensed psychological associates
- Board Certified Behavior Analysts (BCBA)
- Board Certified Behavior Analysts-Doctoral (BCBA-D)
- Applied Behavior Analysis (ABA) licensed/certified providers
To be a TRICARE-authorized provider and deliver care under the TRICARE program, providers must:
- Meet professional licensing and certification requirements
- Be certified by TRICARE
- Be licensed in the jurisdiction where they provide care (Title 32, Code of Federal Regulations, Part 199.6)
Behavioral Health Care Network
The TRICARE behavioral health care network consists of:
- Hospitals
- Inpatient psychiatric units
- Opioid treatment programs (OTP)
- Substance use disorder rehabilitation facilities (SUDRF)
- Partial hospitalization programs (PHP)
- A TRICARE-authorized psychiatric PHP can be a distinct part of an otherwise TRICARE-authorized institutional provider or a freestanding program
- For TRICARE certification, must be currently accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the DHA Director
- For acute care hospital-based PHPs, when a hospital is a TRICARE-authorized provider, the hospital’s PHP is also considered a TRICARE-authorized provider
- Intensive outpatient programs (IOP)
- A TRICARE-authorized psychiatric IOP can be a distinct part of an otherwise TRICARE-authorized institutional provider or a freestanding program
- For TRICARE certification, must be currently accredited by TJC, CARF, CoA, or an accrediting organization approved by the DHA Director
- For acute care hospital-based IOPs, when a hospital is a TRICARE-authorized provider, the hospital’s IOP is also considered a TRICARE-authorized provider
- Residential treatment centers (RTC)
- Must be currently accredited by TJC, CARF, CoA, or an accrediting organization approved by the DHA Director
- Must be licensed as an RTC to provide RTC services within the applicable jurisdiction in which it operates
- For more specific information regarding RTC standards, refer to the TRICARE Policy Manual Chapter 11
To become a network provider, these facilities must complete the TriWest contracting process, unless the facility is a VA facility. These facilities must sign a participation agreement to comply with all TRICARE policies prior to rendering services to TRICARE beneficiaries.
For information regarding PHPs, IOPs, RTCs, OTPs, and SUDRFs, refer to the TRICARE Policy Manual Chapter 11.
Corporate Services Provider Class
The Corporate Services Provider (CSP) class comprises of institutional-based or freestanding corporations and foundations that render principally professional, ambulatory, or in-home care and technical diagnostic procedures. However, CSPs cannot be a professional corporation or professional association. A professional corporation is a form of corporation authorized by state statute for a specified list of licensed professions, often including doctors, lawyers, public accountants and engineers. State law defines a professional association. State law must be consulted for a determination of whether the entity is considered a professional corporation or professional association.
The provider types in this category may include:
- Cardiac catheterization clinics
- Comprehensive outpatient rehabilitation facilities
- Diabetic outpatient self-management education programs (American Diabetes Association accreditation required)
- Freestanding bone-marrow transplant centers
- Freestanding Magnetic Resonance Imaging centers
- Freestanding sleep-disorder diagnostic centers
- Home health agencies (pediatric or maternity management required)
- Home infusion (Accreditation Commission for Healthcare accreditation required)
- Independent physiological laboratories
- Radiation therapy programs
For more information about Corporate Services Provider reimbursement, refer to TPM, Chapter 11, Section 12.1.
DRAFT — pending DHA approval. Submitted for review on 2/15/24.