TRICARE May 2026 Provider Pulse

NEW! Send CLRs, No Fax Required

Providers now have an additional option for sending Clear and Legible Reports (CLR) to military treatment facilities (MTFs), fax free.

When uploading documents through the provider portal on Availity, you can enter “CLR” in the note field. This will trigger a one-way message that will send the CLR directly to MHS Genesis, where the MTF will attach it to the beneficiary’s chart.

You currently have three options for sending CLRs to MTFs:

Use a Health Information Exchange (HIE) that connects with the government’s Joint HIE, such as CommonWell or eHealth Exchange.
Send CLRs directly to MHS Genesis.
Use the new CLR submission through the provider portal by typing “CLR” in the note field when uploading documents.

Please note that this new option is one-way only; MTFs cannot respond to providers using this method. Providers using Joint HIE or direct messaging do not need to use this new functionality.

Reminder: Do Not Report OHI Data When TRICARE is Primary

Please be reminded that providers should not include Other Health Insurance (OHI) or Coordination of Benefits data on the claim submission if the patient does not have OHI that pays primary to TRICARE. Additionally, please do not indicate that the patient has TRICARE or include past TRICARE payments on the claim submission. Including this information can result in OHI being loaded onto the patient’s record and may lead to claim denials for OHI.

TRICARE pays before the following:

Medicaid
TRICARE Supplements
State victims of crime compensation programs
Other federal government programs identified by the Director Defense Health Agency (for example, Indian Health Service)

For more information, please see the TRICARE Using Other Health Insurance web page.

Understanding TRICARE^® Plan Options: What Providers Need to Know

You care for service members, retirees, and their families every day. To support them well, you need to understand the TRICARE health plans they use. When you understand how these plans work, you can provide timely care, file accurate claims, and avoid billing issues.

Confirm TRICARE Coverage Up Front

Confirm your beneficiary’s TRICARE plan before determining coverage or starting treatment. A Uniformed Services ID card does not show plan type, so verify eligibility through the provider portal, Availity. This ensures you know whether the patient is enrolled in TRICARE Prime, TRICARE Select, or a specialty plan, and what referral, authorization, or cost‑sharing requirements apply.

How to Verify Coverage

Log in to the provider portal, Availity.
From the top navigation menu, select Patient Registration.
Open the Eligibility and Benefits Inquiry application.
Select the TRIWEST - TRICARE payer.
Enter the required patient information.
For TRICARE inquiries, the Member ID must be one of the following without dashes or spaces:
- the patient’s nine-digit Social Security Number (SSN)
- the patient’s 11-digit DEERS Beneficiary Number (DBN)
Submit the inquiry to view the patient’s eligibility and benefit details.

The overview below highlights key information to help guide your daily interactions with TRICARE patients.

TRICARE Prime

TRICARE Prime is a managed care option. Beneficiaries have a primary care manager (PCM) who delivers routine care, coordinates treatment, and provides specialty referrals.

TRICARE Prime plans include:

TRICARE Prime: Beneficiaries are assigned to a primary care manager (PCM) who gives routine care, coordinates treatment, and provides referrals for specialty care. Submit referrals to TriWest Healthcare Alliance (TriWest) through the provider portal, Availity. This approach helps your patients get the authorizations they need before they receive care.
TRICARE Prime Remote: TPR is a managed care plan for active duty service members and family members who live and work more than 50 miles away from a military hospital or clinic.
TRICARE Prime Overseas: This managed care option is available in overseas locations near military hospitals and clinics. It supports active duty service members and command-sponsored family members stationed abroad.
TRICARE Prime Remote Overseas: This option supports active duty service members and command-sponsored family members who live in designated remote overseas locations in Eurasia-Africa, Latin America, Canada, and the Pacific.
US Family Health Plan: This TRICARE Prime option works with local, non-profit health systems in six regions. Even though it is part of TRICARE, people enrolled in USFHP get all their care, including pharmacy services, from a primary care provider (PCP) they choose from a network of private doctors. The PCP helps schedule specialist visits in the area and guides the patient’s overall care.

TRICARE Select

TRICARE Select is a preferred provider option (PPO). It gives patients more choices. Beneficiaries may see any TRICARE‑authorized provider without a referral, though some services still need pre‑authorization.

TRICARE Select plans include:

TRICARE Select: TRICARE Select is a self-managed PPO plan available in the United States. Beneficiaries may see any TRICARE‑authorized provider without a referral, though some services still need approval.
TRICARE Select Overseas: This plan covers eligible beneficiaries in any overseas area. Patients must show as TRICARE-eligible in DEERS and must enroll to use this plan.

Specialty TRICARE Plans

Specialty TRICARE plans support Medicare‑eligible beneficiaries, Reserve members, and adult children.

Specialty TRICARE plans include:

TRICARE For Life: TFL is Medicare-wraparound coverage for TRICARE-eligible beneficiaries who have Medicare Part A and Part B. It works worldwide. TFL coverage applies only to the beneficiary who has Medicare and TRICARE eligibility and does not extend to family members.
TRICARE Reserve Select: TRS is a premium-based health plan available worldwide for qualified Selected Reserve members and eligible family members. It works similarly to TRICARE Select, with monthly premiums and specific eligibility requirements.
TRICARE Retired Reserve: TRR is a premium-based health plan for qualified retired Reserve members under age 60 and their eligible family members. It provides coverage until retired Reserve members reach age 60 and qualify for other TRICARE plans.
TRICARE Young Adult: TYA is a premium-based plan for eligible adult children who lose regular TRICARE coverage at age 21 (or 23 if enrolled in college). TYA offers two options, TYA Prime and TYA Select, with medical and pharmacy benefits.

Helpful Tools for Patients

Plan Finder: Plan Finder: This tool lets patients compare TRICARE plans side by side.
Compare Plans: This tool lets patients compare two or more TRICARE health plans side by side. It can help you explain differences in coverage, referrals, and costs so patients understand their options.

For more information on TRICARE health plans, visit: https://www.tricare.mil/Plans/HealthPlans.

Update: Mental Health and Substance Use Disorder Prior Authorization and Admission Notification Requirements

TriWest has changed how we manage nonemergent inpatient mental health and substance use disorder (SUD) admissions. TRICARE policy requires prior authorization for these services, along with intensive outpatient programs and partial hospitalization programs. Only emergent acute psychiatric and emergent acute SUD detox admissions may occur without prior authorization. Facilities must notify TriWest by the next business day after admission and no later than 72 hours after admission.

On May 15, 2026, TriWest implemented the requirements outlined below for all nonemergent mental health admissions, including nonemergent acute psychiatric hospital admissions, psychiatric residential treatment center admissions, psychiatric residential treatment center admissions for children, and inpatient/residential SUD detoxification and rehabilitation care.

When prior authorization is required but not requested:

TriWest will authorize care starting on the date we receive your notification.
Days before the notification date will remain unauthorized and will undergo retrospective review after you file the claim.
If medically necessary, TriWest will pay the claims but the entire episode of care will be assessed a 10% penalty.

When prior authorization exists but the provider does not report the admission within timeliness standards:

TriWest will authorize care starting on the date we receive the admission notice.
Days before the notice will remain unauthorized and will undergo retrospective review after you file the claim.

If medically necessary, TriWest will pay the claim, but the late notice days will be assessed a 10% penalty.

Providers may not bill the patient for this penalty.

Only TriWest, as the TRICARE West Region contractor, may approve prior authorizations. When TriWest issues approval, we notify the requesting provider, the servicing provider, and the beneficiary. Providers may also verify authorization status in the provider and beneficiary portals.

For full policy guidance, review the TRICARE Reimbursement Manual, Chapter 1, Section 28. For assistance, contact the TriWest Mental Health Utilization Management Team at T-5UMMentalHealthTeam@triwest.com. You may also contact Dr. Chris Warner, TriWest Mental Health Medical Director, at cwarner@triwest.com.

Thank you for your continued support to the military community.

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. 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

Summer 2026 TRICARE Policy Updates: What Providers Need to Know About Rare Diseases, Imaging, Mental Health, and Telehealth

Effective June 5, 2026, TRICARE is incorporating Change 49 to the TRICARE Policy Manual (TPM 6010.63‑M) and Change 55 to the TRICARE Operations Manual (TOM 6010.62‑M).

Key affected TPM sections:

Chapter 1, Section 3.1 – Rare Diseases.
Chapter 4, Section 6.1 – Musculoskeletal System.
Chapter 4, Section 15.1 – Male Genital System.
Chapter 5, Section 1.1 – Diagnostic Radiology / Imaging.
Chapter 5, Section 4.1 – Nuclear Medicine (including PET/PET CT indications).
Chapter 7, Section 3.7 – Treatment of Mental Disorders – General.
Chapter 7, Section 22.1 – Telemedicine / Telehealth.

Clinical policy highlights for providers

1. Rare diseases and cardiac sarcoidosis

TRICARE confirms that positron emission tomography (PET) and PET‑CT can be considered for cost‑sharing for the diagnosis of cardiac sarcoidosis.

Practical takeaway for providers:
- When treating rare disease patients, including suspected cardiac sarcoidosis, document the diagnosis, rationale, and supporting literature when available.

2. Musculoskeletal procedures and hip resurfacing

In TPM Chapter 4, Section 6.1 (Musculoskeletal System), TRICARE reinforces coverage for certain FDA‑approved implants and musculoskeletal procedures when clinical criteria are met. As part of this change package, CPT code 27130 (often used in hip resurfacing contexts) is removed from a specific listing related to hip resurfacing with an FDA‑approved device for degenerative joint disease, while maintaining overall musculoskeletal coverage guidance.

Practical takeaway for providers:
- Orthopedic surgeons and coders should confirm current coding guidance for hip resurfacing and related procedures and ensure that documentation clearly supports use of FDA approved devices where required by policy.

3. Male genital system and high‑intensity focused ultrasound (HIFU)

TPM Chapter 4, Section 15.1 (Male Genital System) has been updated to remove HCPCS code C9747 and replace it with CPT code 55880 in the context of high‑intensity focused ultrasound (HIFU) for localized prostate cancer. In this section, TRICARE clarifies that HIFU for localized prostate cancer is considered unproven and, therefore, not covered, even as coding transitions from the HCPCS code to the CPT code.

Practical takeaway for providers:
- Urologists and billing staff should avoid billing HIFU for localized prostate cancer under CPT 55880 for TRICARE patients, as this use remains non covered as unproven under current policy.

4. Diagnostic radiology and MRI of the breast

In TPM Chapter 5, Section 1.1 (Diagnostic Radiology / Diagnostic Imaging), TRICARE removes CPT codes 77058 and 77059 from multiple breast MRI indications. These codes are deleted across:

Lists of covered breast MRI procedures.
Screening MRI for asymptomatic women at risk for breast cancer.
MRI for assessment of implant integrity or suspected implant rupture.
Practical takeaway for providers:
- Radiology departments should ensure that current breast MRI CPT codes (77046 and 77047) are used (rather than 77058/77059)

5. Nuclear medicine: PET/PET‑CT and other indications

TPM Chapter 5, Section 4.1 (Nuclear Medicine) provides a detailed description of nuclear medicine modalities (planar, SPECT, PET/PET‑CT, etc.) and a broad list of PET/PET‑CT coverage indications that include multiple malignant and non‑malignant conditions. The policy reiterates that PET and PET‑CT may be considered for cost‑sharing for the diagnosis of cardiac sarcoidosis (a rare disease update cross‑referenced in Chapter 1).

Practical takeaway for providers:
- Nuclear medicine physicians should verify PET/PET CT indications (oncologic and non-oncologic) against TRICARE policy and clearly document the clinical question and indication, particularly for rare diseases such as cardiac sarcoidosis.

6. Mental health services and neuromodulation

In TPM Chapter 7, Section 3.7 (Treatment of Mental Disorders – General), TRICARE re‑affirms its broad coverage framework for medically or psychologically necessary mental health and substance use disorder (SUD) services delivered by TRICARE-authorized professional and institutional providers. Covered services include acute psychiatric hospitalization, residential treatment for youth, partial hospitalization programs (PHPs), intensive outpatient programs (IOPs), psychotherapy, psychological testing, psychotropic medication management, electroconvulsive therapy (ECT), collateral visits, and medication‑assisted treatment for SUDs.

This revision clarifies neuromodulation and pharmacologic innovations:

Transcranial Magnetic Stimulation (TMS), including repetitive TMS (rTMS), for adults with major depressive disorder is considered proven and is covered when medically appropriate, using CPT codes 90867, 90868, and 90869, with preauthorization required.
The acronym for TMS is corrected throughout, and preauthorization requirements for rTMS are re‑emphasized to ensure failure of, or inappropriateness for, less intensive interventions.
Spravato (esketamine) nasal spray is covered for treatment‑resistant depression and other FDA‑approved indications when accessed via the REMS program, with reimbursement limited to HCPCS codes G2082–G2083 (which bundle drug administration and observation); providers should not bill HCPCS S0013 alone for the drug.

Exclusions in this section include, among others, certain off‑label or unproven neuromodulation and digital therapeutics, such as microcurrent electrical therapy, cranial electrotherapy stimulation, non‑invasive vagus nerve stimulation for PTSD, off‑label TMS for PTSD, off‑label ketamine uses, off‑label Spravato uses, and prescription digital therapeutics like NightWare and EndeavorRx.

Practical takeaway for providers:
- Behavioral health prescribers and neuromodulation programs should ensure that TMS/rTMS and Spravato services meet TRICARE’s medical necessity and preauthorization criteria and are coded correctly; off‑label uses for PTSD and certain digital therapeutics remain non‑covered.

7. Telehealth policy refinements

TPM Chapter 7, Section 22.1 (Telemedicine/Telehealth) updates and clarifies TRICARE’s telehealth framework across synchronous, asynchronous, remote physiological monitoring (RPM), and telephonic services. The section describes:

Telehealth scope and modalities, including real time two way audio video, store and forward services (e.g., teleradiology, telepathology, teledermatology, cardiology), and RPM.
Technical, privacy, and security requirements aligned with HIPAA (and host nation protections overseas), including encryption, secure storage of PHI, and prohibition on using non compliant consumer video platforms unless they are appropriately secured and covered by business associate agreements where needed.
Contractor obligations to instruct providers on licensing, credentialing, emergency planning (especially for mental health), identity verification, documentation of patient and provider locations, and backup communication plans in case of technological failures.

Key reimbursement clarifications include:

Distant site professional services delivered synchronously via interactive telecommunication are reimbursed at the lower of CMAC, billed charges, or negotiated rate, as if delivered in person, by TRICARE authorized providers acting within their scope of practice.
Copayments and cost shares for telehealth mirror those for in person services.
Originating site facility fee Q3014 is payable only when the originating site is an authorized facility (e.g., a TRICARE‑authorized institutional provider or office where services are normally provided) and is not payable when the patient’s home is the originating site; claims with POS 10 (home) are reimbursed at the non‑facility rate and cannot bill Q3014.
For synchronous and asynchronous telehealth, use of CPT/HCPCS codes with appropriate modifiers is required:
- GT or 95 modifiers (and, optionally, POS 02) for synchronous distant site telehealth.
- GQ modifier (and, optionally, POS 02) for asynchronous services.
- During the COVID‑19 pandemic, TRICARE allowed flexibility on POS 02 reporting while maintaining modifier requirements.

The revision also introduces a concise description of telephonic office visits (CPT 98966–98968, 99441–99443, HCPCS G2012) as covered for established patients when medically necessary care does not require in‑person evaluation or visual assessment.

Practical takeaway for providers:
- Ensure telehealth platforms meet security standards; select correct POS and modifier combinations; do not bill Q3014 when the originating site is the patient’s home; and apply the same referral, preauthorization, and medical necessity standards used for in‑person care.