What is TRICARE?

 

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TRICARE – TRICARE West – TriWest Healthcare Alliance

TRICARE

The Health Plan

• Department of Defense (DOD) health care program overseen by Defense Health Agency (DHA)
• Brings together military and civilian health care professionals
• Includes 11 health plan options
• For active duty, National Guard and Reserve, retirees, and their family members; survivors; and certain former spouses

TRICARE West

The Region

• Includes 26 states*
• One of two TRICARE regions in the United States
• TriWest Healthcare Alliance is the TRICARE West regional contractor*

TriWest Healthcare Alliance

The Company

• Regional contractor for TRICARE West Region*
• Third-party administrator for Department of Veterans Affairs Community Care Network Regions 4 and 5
• One purpose: Serving the health care needs of military and Veteran communities

*effective January 1, 2025

TRICARE Program Eligibility

TRICARE provides health care to service members, retirees, and their families.

Those eligible for TRICARE include:

• Active duty service members and their families
• National Guard and Reserve members and their families
• Retired service members and their families
• Retired Reserve members and their families
• Survivors
• Children
• Former spouses
• Medal of Honor recipients and their families
• Dependent parents and parents-in-law
• Foreign Force members and their families

TRICARE plans include:

• TRICARE Prime
• TRICARE Prime Remote
• TRICARE Prime Options – US Family Health Plan
• TRICARE Prime Overseas
• TRICARE Prime Remote Overseas
• TRICARE Select
• TRICARE Select Oversea
• TRICARE For Life
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Young Adult

TRICARE Prime Remote for Active Duty Family Members (TPRADFM)

TPRADFM provides TRICARE Prime benefits to certain active duty family members (ADFMs) who live and work in designated remote locations in the United States and the District of Columbia.

Family members living in remote areas are eligible for TPRADFM if the sponsor leaves for an unaccompanied assignment. If the sponsor is a reserve Component (RC) member on active duty for more than 30 calendar days, family members are eligible for TPRADFM.

TPRADFM benefits include:

• TRICARE Prime
• Access standards
• Benefit coverage
• Cost-shares

TPRADFM does not apply to those enrolled in ADFM in areas that are outside of the 50 U.S. states and District of Columbia.

Health care providers should process care and claims following the TRICARE Overseas Program (TOP) and TRICARE Policy Manual (TPM).

Note: The support team called Specified Authorization Staff (SAS) will not be part of TPRADFM.

Learn more about the TPRADFM program in the TRICARE Operations Manual (TOM), Chapter 16, Section 6.

Delivery Requirements

The Military Health System (MHS) connects the following three groups into one globally linked system:

• Military hospitals and clinics
• Civilian network of providers
• TRICARE-authorized non-network providers

The Defense Health Agency (DHA) issues broad General Policy And Responsibilities guidelines for providing TRICARE related services.

The DOD provides guidelines by regularly updating Title 32 of the Code of Federal Regulations (CFR) to meet organizational and patient needs. For more details on operational guidelines, reimbursement for TRICARE, and policy, visit the following: 

• TRICARE Operations Manual
  • Chapter 1, Section 3.1
• TRICARE Reimbursement Manual
  • Chapter 3
• TRICARE Policy Manual

Join Our Network

are you interested in joining TriWests's network and serving military families?

Go to JoinOurNetwork.TriWest.com

Note: You will need your Federal Tax ID.

A TriWest provider relations representative will contact you once we have processed your request.

TriWest has started the process of notifying interested providers not currently in our network and current network providers about their contract status. Once your contract is fully processed, you will receive a copy of your executed agreement.

Have contract questions? Check out the Provider Contracting Q&A section.

Thank you for your interest in serving our nation’s heroes and their families!

TRICARE Provider Contracting Q&A

Below you’ll find answers to the frequently asked questions regarding TRICARE Provider Contracting.

Q: When did TriWest start the contracting process for T-5?

TriWest is accepting interest forms from providers who wish to join the TriWest network. Beginning in the first quarter of 2024, TriWest started notifying future interested providers and current network providers about their contract status. Providers received copies of executed agreements by the end of 2024.

Q: What kind of contract will my organization receive?

There are three types of contract status changes you might receive:

1. An auto-amendment to your contract, which does not require any action by you to participate in T-5; please retain a copy of this for your records.
2. An amendment that requires your signature, which means you must sign the T-5 amendment to your existing contract and return it to TriWest.
3. A new contract, which means you were not previously a network provider with TriWest, so you must sign a full contract and return it to us to join the network.

Q: What are the new TRICARE reimbursement rates?

Reimbursement rates will differ from past DOD TRICARE rates and differ from Department of Veterans Affairs (VA) rates. For reference, most reimbursement is based upon CHAMPUS Maximum Allowable Charge (CMAC) rates.

Q: Who do I contact if I have more questions about TRICARE contracting with TriWest?

We are happy to answer further questions about the new T-5 contract and how it will work. You may contact TriWest at TRICAREProviderInquiries@triwest.com or please feel free to visit the TriWest website.

Q: What if I have questions about or need help with this online form for interested providers?

Please email TriWest at TRICAREProviderInquiries@triwest.com or call 1-888-874-9378.

Q: I am interested in joining the TRICARE East Region network. How do I do that if TriWest is only covering the TRICARE West Region?

If you are inquiring about TRICARE for the East Region, please contact Humana Military East Region at 1-800-444-5445 or visit www.tricare-east.com.

Q: I was a provider in the TRICARE East Region with Humana Military, and my contract moved to TriWest in January, what does this mean?

All provider agreements supporting TRICARE under Humana for the states that transitioned to the TRICARE West Region were assigned to TriWest with an effective date of January 1, 2025. This means that TriWest has become a party to the contract, replacing Humana, for all care delivered on and after that date. Communication has been sent to impacted providers. No further action is needed currently.

The six states that moved from the East Region to the West Region with dates of service that started on or after January 1, 2025, are:

• Arkansas
• Illinois
• Louisiana
• Oklahoma
• Texas
• Wisconsin

Q: While TRICARE covers some services for beneficiaries, what programs/specialties are excluded from provider contracting through TriWest as the third-party administrator (TPA)?

TriWest is not contracting for General Dentistry, Endodontics, Pharmacy, or Chiropractic services for TRICARE. These services may receive coverage under other TRICARE programs or contractors but not through TriWest. Beneficiaries eligible for both TRICARE and Medicare under TRICARE For Life can receive services through another contractor.

Q: Where can I learn more about TRICARE’s transition to TriWest?

Please visit the Military Health System’s contract transition page for more information.

Q: Did referrals and authorizations that were already in place transfer from the previous contractor to TriWest?

TriWest accepted unexpired referrals and pre-authorizations from Health Net Federal Services that were issued prior to Jan. 1, 2025. These were valid through their expiration or June 30, 2025, whichever came first. TriWest also accepts valid referrals and pre-authorizations from Humana Military if the beneficiary lives in a state that moved to the new West Region. These states are Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin.

Q: Now that my contract is complete, are there any other steps I should take regarding the TriWest transition?

Ensure you are registered for a free account on Availity.com. Availity is an online platform where you can manage multiple health plans you accept in one place. TriWest uses Availity as its secure provider portal. For TRICARE, TriWest has a unique TRICARE Payer Space on Availity where you can:

• Submit claims and check claims status
• Access authorizations
• Manage your demographic information (such as address and phone number)
• Find tools and resources like the Provider Handbook, Quick Reference Guides, and more
• Take training on TRICARE processes and procedures

If you don’t already have an account on Availity, register now at  www.availity.com.

If you need help with registration or have questions about your Availity account, call Availity at 1-800-282-4548.

Review the TriWest TRICARE West Region Provider Handbook. It contains information about program requirements, claims submission, eligibility, referrals and authorizations, and beneficiary out-of-pocket costs.