TRICARE January 2026 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 the recalculated claim results in an overpayment of cost shares by the beneficiary, you should refund the beneficiary promptly.

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

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.

Documenting Behavioral Health Outcome Measures: What TRICARE Providers Should Know

In accordance with Chapter 7, Section 6 of the TRICARE Operations Manual, TRICARE network behavioral health providers and facilities are required to track and document specific outcome measures during patient visits. There is no need to submit these to TriWest, but providers should include them in their documentation in case of audit.

This requirement applies across all behavioral health care settings and helps support both quality care and program compliance.

Required Timing for Outcome Measures

For patients with a post-traumatic stress disorder (PTSD), an anxiety disorder, or a depressive disorder, standardized outcome measures must be administered at treatment baseline, at discharge, and every 60 days during treatment. Recommended versions are linked below and are also listed under References.

• Posttraumatic Stress Disorder -- PSTD Checklist (PCL-5)
• Anxiety Disorders – Generalized Anxiety Disorder screen (GAD-7)
• Depressive Disorders – Patient Health Questionnaire
  • PHQ-9
  • PHQ-9 modified for Adolescents (PHQ-A)

Importance of Outcome Measures

Using these standardized tools regularly helps providers:

• Support efficient history-taking, documentation, and treatment planning
• Assess patient progress over time
• Give patients a clear way to visualize their improvement

Along with other clinical factors, TriWest reviews how providers use behavioral health outcome measures as part of its evaluation of care quality. Consistent and accurate documentation helps demonstrate adherence to TRICARE requirements and supports continual quality improvement.

If you have questions about this requirement, please call TriWest customer service at 888-TRIWEST (874-9378).

For more information please reference the PHQ-9 for depression in adults 18 and older, the PHQ-A for depression in children 11-17 years old, the GAD-7 for anxiety screening in adults, and the PCL-5 for PTSD screening in adults.

Avoid Common TRICARE Claims Delays

Submitting clean, timely claims helps ensure faster processing and payment. Avoid unnecessary delays by keeping these practices in mind:

• File claims electronically: Electronic claims submissions are required for TRICARE network providers and are less likely to be rejected than paper claims. Enrolling in Electronic Data Interchange (EDI) or Availity’s Basic Clearinghouse can improve both speed and accuracy.
• Submit claims promptly: To help prevent denials or late filings, submit claims as soon as possible, ideally within 30 days of service.
• Coordinate Other Health Insurance (OHI): Be sure to attach OHI Explanation of Benefits and submit within 90 days of the primary insurer’s decision to avoid issues with coordination.
• Check claims status before resubmitting: Use Availity to track claims status. If a claim shows as “in process” it has been received. Avoid submitting duplicates, which can create delays.

For more about avoiding TRICARE claims delays see the TRICARE Claims Instructions web page.

TRICARE Provider Handbook Updates

A new section, Use of Artificial Intelligence, will be added to the TRICARE Provider Handbook:

Use of Artificial Intelligence

TriWest does not prohibit the use of artificial intelligence (AI) technology by providers to deliver care, however the Provider must ensure that its use of AI complies with all applicable state and federal laws and regulations. Artificial Intelligence or AI refers to a machine-based system that can, with respect to a given set of human-defined objectives, input or prompt, as applicable, make predictions, recommendations, data sets, work product (whether or not eligible for copyright protection), or decisions influencing physical or virtual environments. The Provider is prohibited from using AI for any functions impact covered services delivered to Beneficiaries without review of a qualified clinician. Providers using AI must be careful to ensure that the implementation of such technologies are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended and its implementing regulations and guidance, and applicable federal, state, or local privacy regulations.

Clinical Records submitted to TriWest for any purpose will be accepted as long as:

1. The provider discloses any use of generative AI.
2. The records demonstrate oversight by a clinician of the documentation submitted.
3. The provider maintains audit trails of the AI involvement and clinician validation.
4. Systems used maintain compliance with HIPAA and other applicable privacy regulations.
5. Clinical Records must always comply with requirements of this Handbook and the rules applicable to the TRICARE manuals.

Providers agree to provide TriWest with all necessary information requested to describe their use of the AI tool(s) and how the Provider oversees, monitors, and evaluates the performance and legal compliance of such AI tool(s). Providers must also allow TriWest to audit its use of AI, as requested from time to time, and cooperate with TriWest with regard to any regulatory inquiries related to such AI use in connection with TRICARE.