December 2025 Provider Pulse

Notice on TRICARE Claims Payments

Please be advised that a systems processing error caused certain claims to be incorrectly processed as non-network instead of in-network, resulting in incorrect payments or overpayments. This issue has impacted a limited number of TRICARE providers and beneficiaries.

As a result of this error, cost shares and catastrophic caps may also be affected. All impacted claims are currently under review by our claims processor, PGBA, to ensure accuracy and appropriate correction.

If your claim is identified as impacted, you will receive a miled letter with instructions on repayment from PGBA. Recoupment efforts began November 24, and affected providers can expect to receive official notices from PGBA over the next 120 days.

We sincerely apologize for any inconvenience this issue may have caused and appreciate your patience as we work to resolve these matters quickly and accurately.

Complete the Required Annual ACD Provider Training

All Autism Care Demonstration (ACD) providers must complete the ACD Annual Training Module to remain compliant with Chapter 18, Section 3 of the TRICARE Operations Manual requirements.

Completion of this training is required for all ACD providers. It is offered as an on-demand, web-based module that can be accessed at any time for your convenience. If the training is not completed Failure to complete the required training may result in a 10% reduction of claims reimbursement in accordance with program requirements.

Access the training:

• Log in to Availity.com.
• Go to the TRICARE West Payer Space.
• Click on the Access TriWest Leaning Center tile.
• Search “Annual Provider Training”.
• You can either enroll for a later training date or begin the training by clicking “Start Now”.

This course provides a comprehensive overview of topics essential to delivering high-quality and compliant ABA services:

• ACD requirements and responsibilities of ABA providers
• Correct billing practices and claims filing
• Authorization procedures, program exclusions, an support documentation
• Medical records standards and expectations

TRICARE Coverage for Portable CPAP Machines, Sensory Integration Training, Sleep Studies, Hearing Aids, and Home Infusion Therapy

You may encounter patients who need specialized services such as portable continuous positive airway pressure (CPAP) machines, sensory integration training, sleep studies, hearing aids, or home infusion therapy. TRICARE coverage for these services comes with specific requirements. Knowing the key guidelines can help ensure patients receive the care they need without delays.

Coverage highlights

• Portable CPAP machines: Covered only for active duty service members with obstructive sleep apnea who travel for duty at least three days per month or are about to be deployed. CPAPs must include humidification and portable battery capability.
• Sensory integration training: Considered unproven and not reimbursed separately or in combination with other therapies.
• Sleep studies: Requires a referral and must follow TRICARE’s location priority order (military treatment facility, network, non-network, then home study). For step-by-step requirements, documentation guidance, and Current Procedural Terminology coding, see the Sleep Studies Quick Reference Guide.
• Hearing aids: Covered only in cases of profound hearing loss. Retirees are not eligible, though reduced-cost options may be available through the Retiree-At-Cost Hearing Aid Program.
• Home infusions: Available for homebound patients, with limited coverage for non-homebound patients when medically appropriate and with preauthorization.

For more guidance visit the Special Referrals web page.

Help is Available for Beneficiaries Enrolling in ACD

TriWest now offers enhanced support for TRICARE beneficiaries seeking enrollment in the Autism Care Demonstration (ACD), which provides applied behavior analysis services for individuals diagnosed with autism spectrum disorder (ASD).

Families can receive up to 180 days of assistance from a dedicated ACD specialist who can help:

• Explain ACD eligibility requirements and available services.
• Obtain referrals for ASD diagnostic evaluations.
• Coordinate with providers to ensure all documentation is complete and submitted.

Please encourage eligible TRICARE families to call 833-818-2525 to request “ACD eligibility assistance.”

Learn more by visiting the Autism Care Demonstration web page.

TRICARE Provider Handbook Updates

The following information will be added under the TRICARE Referrals and Authorizations section:

Please note: The employment of physicians by certain U.S. federal agencies is not constrained by normal state licensing statutes, and Joint Commission guidance does not prohibit VA or military physicians from ordering services where they are not licensed by the state. The requirement that an ordering physician be licensed in the state does not apply to a VA or military doctor who submits the order in the course of their duties for the Government. The requirement for appointing a physician to a position at the VA are codified at 38 U.S.C.  § 7402(b)(1), and for DOD providers at 10 U.S.C. § 1094 et seq., which require a valid state license, but do not require the physician to be licensed in the state where they practice. The statutes allow VA and DOD to employ a provider in any facility (in any state) provided he or she has a license to practice in any state, territory, or possession of the United States, and has not had their license revoked in any other state. Joint Commission guidance requires a valid state license “as required by law,” but since federal law exempts DOD providers from requiring a license in the same state where they practice, there is no conflict with the Joint Commission in these cases.