TRICARE August 2026 Provider Pulse

Correction: Understanding TRICARE IOP Level of Care

The July TRICARE Provider Pulse article on Intensive Outpatient Programs (IOPs) erroneously suggested that IOPs must include a minimum of nine hours per week of clinical programming. However, the official TRICARE definition of an IOP is a program that “typically consists of between six and nine or more hours a week ... (minimum two hours per treatment day)."

Reference: TRICARE Policy Manual, Chapter 7, Section 3.15

TRICARE Policy Manual Outlines New TENS Device Guidelines

According to updates to Chapter 8 (section 20.2) of the TRICARE Policy Manual, Transcutaneous Electrical Nerve Stimulation (TENS) devices will only be covered for treatment of post-operative pain. They are excluded from coverage for any other purpose. This coverage is limited to an initial period of 30 days from the day of the surgery. Additionally, it can only be extended to a maximum of 90 days, with required monthly documentation of necessity by an authorized provider.

What is covered
- TENS devices and associated supplies
- Use for acute post operative pain only
- An initial 30 day coverage period, with the option to extend up to a maximum of 90 days if medically justified

What is not covered
- TENS devices for any other condition or type of pain
- Use for chronic pain, including low back pain

What’s new in this update
- A defined coverage window (30 days, extendable to 90)
- Clarification that post operative pain is the only covered use
- Exclusion of all other indications beyond the post operative setting

Updates to the TENS device policy went into effect July 13, 2026, under TRICARE Policy Manual Change 53.

When is a New TRICARE PCM Referral Required?

It is important to know when an existing specialist may continue managing the care of a beneficiary and when a new primary care manager referral is required. The following considerations can help clarify.

Referral Duration

Evaluation and Treatment referrals are generally valid for 365 days. Once the referral expires, a new PCM referral is required for continued specialty care. Authorizations related to the episode of care cannot extend beyond the validity end date of the original PCM referral.

Active Duty Service Members

While an active referral is in place, the treating specialist may request additional medically necessary services within the same specialty and/or ancillary services (such as imaging, lab tests, and physical therapy) related to the specialty being treated.

A new PCM referral is required when the beneficiary needs evaluation or treatment by a different specialty (secondary specialty referral) or the existing referral has expired.

Non-Active-Duty Beneficiaries

While an active referral is in place, the treating specialist may request additional necessary services within the same specialty and/or medically necessary ancillary services related to the condition being treated. Specialists may request additional specialty care when appropriate, subject to TRICARE policy and authorization requirements.

Outpatient mental health services for non-active-duty beneficiaries generally do not require a PCM referral, although prior authorization requirements may still apply for certain services.

All requests are still subject to covered benefit and medical necessity review before approval. A referral is specialty specific. If care is needed from a different specialty than the one originally referred to, a new PCM referral is generally required unless otherwise allowed under TRICARE policy.

Access the referral management system through Availity to learn more.

Critical TRICARE Autism Care Demonstration Updates

TRICARE Autism Care Demonstration providers should be aware of important updates and clarifications regarding Applied Behavior Analysis CPT codes, location restrictions, and Treatment Plan submission requirements.

1. Location Restrictions for CPT Codes

Treatment Plan recommendations must strictly align with location-specific guidelines. Please ensure your authorization requests for individual CPT codes match the approved locations listed below:

97151: Community, Home, Clinic
97153: School, Community, Home, Clinic
97155: Community, Home, Clinic
97156: Home, Clinic (Note: Telehealth is permitted after the initial 6 months.)
97157 / 97158: Clinic only

2. CPT Code 97155 Requirement & 10% Recoupment Penalty

To maintain clinical oversight, CPT code 97155 must be billed at least once per calendar month by the ABA Supervisor when direct treatment is being rendered under any of the following codes: 97153, 97156, 97157, or 97158.

Penalty for Non-Compliance: If the requirements for CPT code 97155 are not met, a 10% penalty will be applied to all ABA claims across the entire six-month authorization period, resulting in a recoupment of funds. See TRICARE Operations Manual 8.11.6.1.3 for full details of requirements.

Please update your scheduling, clinical recommendations, and billing workflows immediately to reflect these requirements and avoid financial penalties. These guidelines ensure compliance with TRICARE Operations Manual (TOM) Chapter 18, Section 3.

Provisional Credentialing Not Allowed Under TRICARE Contract

To help ensure compliance with TRICARE West Region credentialing requirements, TriWest Healthcare Alliance reminds network providers that provisional credentialing is not permitted under the TRICARE contract. Providers must fully satisfy all applicable credentialing and certification requirements before participating as a TRICARE network provider.

Providers may not participate in the TRICARE West Region network based on:

Provisional licensure
Provisional certification
Temporary credentialing approval
Incomplete credentialing requirements

Participation may begin only after all applicable credentialing requirements have been completed and approved by TriWest.

Practices should verify that newly hired providers have:

Met all applicable TRICARE qualification requirements
Completed the required credentialing process
Received approval to participate in the network before treating patients as participating providers

For complete credentialing requirements, visit the Provider Information  section of the TRICARE Provider Handbook.