June 2025 Provider Pulse

TRICARE PCM Referral Approval Waiver Ending June 30

The TRICARE primary care manager (PCM) referral approval waiver is ending June 30. Starting July 1, new PCM referrals for care are required for outpatient TRICARE-covered procedures, services, and equipment orders, and require approval from TriWest.

Be prepared for changes starting July 1:

• Review referral guidelines on the TRICARE website for quick reference guides and access to referral management system training.
• Use TriWest’s online referral management system, to submit and view authorization and referral requests. You can find this on Availity within TriWest’s TRICARE Payer Space under Applications.
• An Alternative Referral and Authorization Form is also available on Availity. For more information, see the Alternative Referral and Authorization Form Quick Reference Guide.

How to Ensure Care Continues for Your TRICARE Patients

Beneficiaries who currently have a PCM referral waiver for specialty care effective after January 1, 2025, may continue their specialty care with their specialist through September 30, 2025, without paying a point of service charge.

Starting October 1, the beneficiary must go back to their PCM to get approval on a new referral to see the specialist. Standard referral requirements will resume after October 1. Any continuing care must be supported by a new referral.

How to Prepare for July 1

• Standard referral and authorization requirements apply starting July 1. Submit referral and authorization requests to TriWest for beneficiary care.
  • Need quick tips? Access the How to Submit Referrals and Authorizations Quick Reference Guide.
  • Need training? Go to the TriWest Learning Center in Availity for referral and authorization webinars and on demand options.
• Proactively identify any patients operating under the PCM referral waiver and get prepared. Coordinate with their PCM to obtain appropriate referrals before October 1.

Autism Care Demonstration EFT Waiver Expires June 30

As a reminder, the Electronic Funds Transfer (EFT) waiver for Autism Care Demonstration (ACD) providers will expire on June 30, 2025.

Under this waiver, ACD providers were permitted to receive reimbursement without enrolling in EFT. However, starting on July 1, all ACD providers in the TRICARE West Region must be enrolled in EFT to receive claims payments.

You can enroll in EFT and/or ERA electronically through Availity, or follow these guidelines to enroll.

We appreciate your continued care for TRICARE ACD beneficiaries.

Referrals and Authorizations FAQ Just Got an Update

Get quick answers to common questions about submitting referrals and authorizations with updated guidance to make your workflow easier.

What’s New?

• Tips for navigating the tool more efficiently.
• Submitting referrals and authorizations through the online referral management system on Availity.
• How to send referrals and authorizations online.
• How to find and manage current referrals and authorizations.

Read the updated FAQ.

Need More Support?

We offer live training every weekday (Monday to Friday). You can join any time — no sign-up needed.

You can also watch past sessions in the TriWest Learning Center on the Provider Portal. Short videos can also be found in the TRICARE West Region Payer Space.

Reminder: Update Your Provider Directory Information

To ensure TRICARE beneficiaries can access the care they need, it is essential that the West Region Provider Directory contains complete and accurate information for all TRICARE providers.

You can make changes to your provider data through the directory link in Availity. Learn how to update your information by referencing the Provider Directory Change Request FAQ.

New Process: Attach Documents to Alternative Referral/Authorization Form

The fastest way to ensure care for your patients is to submit referral and authorization requests via the online referral management system on the Provider Portal in Availity.

However, if you encounter problems, you can use the Alternative Referral and Authorization Form, also on the Provider Portal in Availity. It is now even easier to use the form. We’ve added the ability to attach medical documentation directly to the online form instead of faxing.

Don’t have an Availity account? It is simple to register for one. Visit Availity to create your free account, enroll in training, and find other helpful resources. See How to Register as a New User Quick Reference Guide for details.

Once you’re in, you can complete the recommended training courses in Availity under “Help and Training” in the upper right corner including webinars, microlearning videos, and eSeminar learning paths.

For more information, check out the Introduction to the Provider Portal Quick Reference Guide.

TRICARE Provider Handbook Updates

There are currently no updates to the TRICARE Provider Handbook.