September 2025 Provider Pulse

New Guides for Specialized Therapy and Autism Care Demonstration

If you provide concurrent physical, occupational, or speech therapy services to TRICARE patients under the Autism Care Demonstration (ACD), a new guide is available to help you submit claims properly.

This guide covers billing for physical, occupational, or speech therapy services under TRICARE, including:

• What procedure codes to charge when submitting claims.
• Who can write the order or script for each type of therapy.
• Where to find more information on TRICARE policy and exclusions for each type of therapy.
• How to bill for physical, occupational, or speech therapy services using one of three methods: a primary care manager referral, adding additional information to your claim, or faxing.

Read the Billing for Physical, Occupational, and Speech Therapy Criteria Quick Reference Guide for more information.

Billing Guidance for Concurrent Care and Session Times under ACD

As an Autism Care Demonstration (ACD) provider, you may sometimes have to render Applied Behavioral Analysis (ABA) services to a patient at the same time as another ACD provider, or you may need to bill for multiple ABA services that you carried out at the same time.

In a situation where you are delivering concurrent care, how should you submit a TRICARE claim?

This guide covers what you need to know to submit a concurrent care ACD claim, including:

• How to document session times for an Electronic Data Interchange (EDI) or XPressClaim claim.
• The TRICARE Operations Manual's guidelines on how to bill the time for concurrent care and restrictions on how to provide concurrent care under TRICARE.
• The Current Procedural Terminology (CPT) modifier combinations you can bill for during concurrent care.

Certification Required for TRICARE ABA Providers

To become a TRICARE ABA provider, you must sign a Participation Agreement and be TRICARE certified. TriWest will certify ABA providers for TRICARE within 10 business days from the receipt of a complete application that meets all certification requirements.

Once the certification process is complete, you will be notified by TriWest’s certification team. Please reference the TRICARE West Region ACD web page for more information about ACD.

For more information see the Billing Guidance for Concurrent Care and Session Times under the Autism Care Demonstration Quick Reference Guide.

TRICARE Referrals Under Waiver End September 30

Please be reminded that if you are seeing a TRICARE Prime beneficiary through the referral waiver process, care under that waiver will end September 30. After this time, the beneficiary will need to go back to their primary care manager (PCM) to get a new referral to see their specialist.

Starting October 1, standard referral requirements will resume, and any continuing care must be supported by a new referral. TRICARE Select Beneficiaries do not need a referral, but do require pre-authorization for some services. Providers should proactively identify affected patients and coordinate with PCMs to obtain appropriate referrals prior to October 1.

West Region authorizations issued prior to January 1, 2025, also end on September 30. In order to ensure continuity of care, a beneficiary must go back to their primary care manager to get a new referral to their specialist, and that referral must be approved by TriWest.

Review referral guidelines, quick reference guides, and access the referral management system on the TRICARE West Region provider web page.

Program Integrity: Accurate Provider Representation Matters

TriWest is committed to ensuring beneficiaries receive care from providers they trust. For that reason, any false or misleading representation of a provider’s identity, services, or qualifications is strictly prohibited under TRICARE.

Any misrepresentation or deception that results in unauthorized TRICARE payments or benefits is considered fraud.

Examples of fraud include but are not limited to:

• Billing for unrendered services
• Upcoding, or
• Practicing without a license.

These rules apply to both network and non-network providers who treat TRICARE beneficiaries, and noncompliance can result in civil, criminal and/or administrative consequences.

For more information on TriWest Program Integrity, visit the Fraud, Waste, and Abuse web page.

Learn More About Wellness Support for TRICARE Patients

Help beneficiaries take the next step towards better health by sharing resources provided by our wellness programs under Population Health and Disease Management:

• Pre-recorded Webinars: Population and Disease management has been busy at work putting together pre-recorded webinars to educate beneficiaries. June’s pre-recorded webinar, Protect Your Skin: Cancer Screening Compliance, shares valuable information on skin cancer that is broken down from how to protect against UVA and UVB, how to do skin checks, and how to stay compliant with screenings.
• Wellness Webpage Campaigns: in observance with monthly initiatives, our team has developed campaign webpages that speak to the month’s observances. You can refer beneficiaries to the wellness webpage campaigns, TRICARE Skin Mission: Scan and Protect web page, and On a Mission to Heal: Navigating Posttraumatic Stress.
• Tobacco and Vaping Cessation (T&V) Line: Encourage beneficiaries to call the T&V cessation line, 833-818-2414, for support to quit smoking or vaping. More resources and education are located on the TRICARE Tobacco and Vaping Cessation web page.

You can refer beneficiaries, or have beneficiaries refer themselves, through the beneficiary portal for the following conditions:

• Anxiety
• Asthma (Pediatric and Adult)
• Coronary Artery Disease
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
• Depression
• Diabetes (Pediatric and Adult)
• Long-Covid
• PTSD

Unless indicated otherwise, disease management programs currently serve patients 18 years of age and older. Help us spread the word to beneficiaries by providing them with education and resources specifically made to lead a healthy life.

Follow TRICARE Policy for Issuing CPAPs

TRICARE network providers are reminded to observe TRICARE policy for issuing portable continuous positive airway pressure (CPAP) machines to active duty service members (ADSM) who have obstructive sleep apnea.

According to the TRICARE Operations Manual (TOM), Chapter 17, Section 3, portable CPAP devices are covered as long as the ADSM meets the following criteria and it is documented on the patient’s referral:

• The ADSM has an Obstructive Sleep Apnea (OSA) diagnosis.
• The ADSM travels on official business at least three days per month or is being deployed.

If the ADSM does not currently have a CPAP machine and meets the travel criteria, they are eligible to receive only a portable CPAP machine, not a non-portable CPAP machine. If the ADSM has a non-portable CPAP and meets the travel criteria, they can get an additional portable CPAP machine. The portable device should have humidification and battery capability.

Upon the ADSM’s initial referral for a CPAP device, TriWest will authorize a portable device if criteria are met. TriWest will not authorize a standard CPAP device in addition to a portable device.

When billing for portable CPAP devices, network providers should use Healthcare Common Procedure Coding System (HCPCS) code E1399 when billing. TriWest will reimburse based upon the billed charge.

For more information regarding CPAPs, refer to the TRICARE Operations Manual (TOM), Chapter 17, Section 3. For more information regarding TriWest and the TRICARE program, refer to the TriWest TRICARE West Region Provider Handbook.

TRICARE Provider Handbook Updates

There are currently no updates to the TRICARE Provider Handbook.