TRICARE Program

Beneficiary Types

TRICARE offers comprehensive medical and behavioral health benefits to all TRICARE beneficiaries. Beneficiary types include:

• Sponsors – active duty, retired, and Guard/Reserve Members
• Family members – spouses and children who are registered in Defense Enrollment Eligibility Reporting System (DEERS)

It is important to be aware of the TRICARE program plan options available according to beneficiary category. To view the most current information on these plans, please refer to the links below.

Plan	Link to More Information
TRICARE Prime	tricare.mil/Plans/HealthPlans/Prime
TRICARE Prime Remote	tricare.mil/Plans/HealthPlans/TPR
TRICARE Prime Overseas	tricare.mil/Plans/HealthPlans/TPO
TRICARE Prime Remote Overseas	tricare.mil/Plans/HealthPlans/TPRO
TRICARE Select	tricare.mil/Plans/HealthPlans/TS
TRICARE Select Overseas	tricare.mil/Plans/HealthPlans/TSO
TRICARE For Life	tricare.mil/Plans/HealthPlans/TFL
TRICARE Reserve Select	tricare.mil/Plans/HealthPlans/TRS
TRICARE Retired Reserve	tricare.mil/Plans/HealthPlans/TRR
TRICARE Young Adult	tricare.mil/Plans/HealthPlans/TYA
US Family Health Plan	tricare.mil/Plans/HealthPlans/USFHP

TRICARE Prime and TPR are managed care options offering the most affordable and comprehensive coverage. ADSMs must enroll in TRICARE Prime or TPR. ADFMs, retirees and their families, and others may choose to enroll in a TRICARE Prime or TRICARE Select option.

When on active duty orders for more than 30 consecutive days, National Guard and Reserve members are covered as ADSMs and must enroll in TRICARE Prime or TPR. During activation, their eligible family members are covered as ADFMs and may enroll in TRICARE Prime, TPR, or TRICARE Select.

The following table provides a summary of the TRICARE plans administered by TriWest for the West Region.

Plans	Description	Availability	Provision of Care	Features
TRICARE Prime	A managed care option offering the most affordable and comprehensive coverage.	In the United States in Prime Service Areas	•  Get most care provided by assigned Primary Care Manager (PCM) (military or network provider) •  PCM refers to specialists for care they cannot provide	•  Enhanced vision coverage and preventive services •  Time and distance access standards •  Fewer out-of-pocket costs •  Beneficiary does not file claims (in most cases)
TRICARE Prime Remote	A managed care option offering the most affordable and comprehensive coverage to active duty families in remote U.S. locations.	In designated remote U.S. locations, more than 50 miles from a Military Treatment Facility (MTF)	•  Get most care provided by assigned PCM (network provider, if available, otherwise any TRICARE-authorized provider) •  PCM refers to specialists for care they cannot provide	•  Enhanced vision coverage and preventive services •  Time and distance access standards •  Fewer out-of-pocket costs •  Beneficiary does not file claims (in most cases)
TRICARE Select	A preferred provider network option available to eligible beneficiaries not enrolled in TRICARE Prime (except ADSMs and TRICARE For Life beneficiaries). Offers the most freedom of choice.	United States	•  Get care from any TRICARE-authorized provider (network or non-network) •  Referrals not required •  Some services require prior authorization	•  Costs vary depending on type of provider •  Beneficiary may have to pay for services when received and file for reimbursement
TRICARE Reserve Select	A preferred provider network option available for qualified National Guard and Reserve members.	Worldwide	•  Get care from any TRICARE-authorized provider (network or non-network) •  Referrals not required •  Some services require prior authorization	•  Must qualify •  Costs vary depending on type of provider •  Beneficiary may have to pay for services when received and file for reimbursement
TRICARE Retired Reserve	A preferred provider network option available to qualified retired Reserve members.	Worldwide	•  Get care from any TRICARE-authorized provider (network or non-network) •  Referrals not required •  Some services require prior authorization	•  Must qualify •  Costs vary depending on type of provider •  Beneficiary may have to pay for services when received and file for reimbursement
TRICARE Young Adult (Select)	A preferred provider network option available to qualified adult children of eligible sponsors.	Worldwide	•  Get care from any TRICARE-authorized provider (network or non-network) •  Referrals not required •  Some services require prior authorization	•  Must qualify •  Referrals are not required, but some care may require prior authorization •  Beneficiary may have to pay for services when received and file for reimbursement
TRICARE Young Adult (Prime)	A managed care option offering the most affordable and comprehensive coverage available to qualified adult children of eligible sponsors.	In the United States in Prime Service Areas	•  Get most care from assigned PCM (military or network provider) •  PCM refers to specialists for care they cannot provide	•  Must qualify •  Enhanced vision coverage and preventive services •  Time and distance access standards •  Fewer out-of-pocket costs •  Beneficiary does not file claims (in most cases)
TRICARE Young Adult (Prime Remote)	A managed care option offering the most affordable and comprehensive coverage in remote U.S. locations available to qualified adult children of eligible sponsors.	In designated remote U.S. locations, more than 50 miles from an MTF	•  Get most care provided by assigned PCM (network provider, if available, otherwise any TRICARE-authorized provider) •  PCM refers to specialists for care they cannot provide	•  Must qualify •  Only available to children of active duty service members enrolled in TRICARE Prime Remote •  Time and distance access standards •  Fewer out-of-pocket costs •  Beneficiary does not file claims (in most cases)

Beneficiary Rights

TRICARE beneficiaries have the right to:

• Accurate, easily understood information so they can make informed decisions about their TRICARE health plan, providers, and facilities.
• A choice of health care providers that ensures access to high-quality health care.
• Emergency health care services when and where they need it. Emergency services coverage is available without authorization if a beneficiary has reason to believe their life is in danger or they would be seriously injured or disabled without immediate care.
• Understand their diagnosis, treatment, or prognosis, as explained by their provider.
• Fully participate in all decisions about their care. If a beneficiary cannot make their own decisions, they have the right to be represented by someone else. This could be a family member or conservator.
• Considerate, respectful care from all health care system members. Beneficiaries are protected against discrimination based on:
  • Race
  • Ethnicity
  • National origin
  • Religion
  • Sex
  • Age
  • Mental or physical disability
  • Sexual orientation
  • Genetic information
  • Source of payment
• Communicate confidentially with their health care team and have their confidential information protected by law.
• Review, copy, and request amendments to their medical records.
• A fair and efficient process for resolving differences with their health plan, health care providers, and the institutions that serve them.

Visit tricare.mil/ for more information about beneficiary rights.

TRICARE Eligibility

TRICARE is a health program for Uniformed Service members and their families, National Guard/Reserve members and their families, survivors, former spouses, Medal of Honor recipients and their families, and others registered in DEERS. See page for more information.

Verifying Benefit Coverage

Civilian providers can use the TriWest online Referral and Authorization Decision Support (RADS) tool to determine if an approval from TriWest is required. The online tool also provides procedure codes, services, and procedure coverage information.

TRICARE Program Options

TRICARE Pharmacy Program

The TRICARE Pharmacy Program provides prescription drug coverage through safe, easy, and affordable options. TRICARE beneficiaries are eligible for the TRICARE Pharmacy Program managed through pharmacy contractor, Express Scripts^® Pharmacy. For more information on how beneficiaries can sign up for secure services with Express Scripts, download the free mobile app, search the TRICARE formulary, and check pharmacy costs (refer to the TRICARE Pharmacy Program webpage).

TRICARE beneficiaries have the following options for filling prescriptions:

• Military pharmacies
• TRICARE Pharmacy Home Delivery
• TRICARE retail network pharmacies

For information on how beneficiaries may be able to get prescriptions filled from a non-network pharmacy, see the Non-Network Pharmacy webpage.

Transitional Health Care Benefits

TRICARE offers three options for beneficiaries separating from active duty or who are losing TRICARE eligibility:

• Transitional Assistance Management Program (TAMP)
• Transitional Care for Service-Related Conditions Program (TCSRC)
• Continued Health Care Benefits Program (CHCBP)

Transitional Assistance Management Program (TAMP)

TAMP provides 180 days of health care benefits after regular TRICARE benefits end. Beneficiaries do not have to pay any premiums for TAMP.

TAMP may cover beneficiaries and their family members if they are:

• Involuntarily separating from active duty under honorable conditions, including:
  • Members receiving a voluntary separation incentive (VSI) or
  • Members receiving a voluntary separation pay (VSP) and cannot receive retired or retainer pay upon separation
• A National Guard or Reserve member separating from a period of more than 30 consecutive days of active duty served for:
  • A pre-planned mission
  • Support of a contingency operation
  • Support of the government coronavirus (COVID-19) response
• Separating from active duty following involuntary retention (stop-loss) in support of a contingency operation
• Separating from active duty following a voluntary agreement to stay on active duty for less than one year in support of a contingency operation
• Receiving a sole survivorship discharge
• Separating from regular active duty service and agreeing to become a member of the Selected Reserve of a Reserve Component. The Service member must become a Selected Reservist the day immediately following release from regular active duty service to qualify

The Services determine TAMP eligibility and document eligibility in DEERS. TAMP eligibility can be viewed online via milConnect.

Qualified Service Members and their families are eligible to use one of the following health plan options* in addition to MTFs:

• TRICARE Prime (where locally available)
• TRICARE Select
• US Family Health Plan(if the beneficiary lives in a designated location)
• TRICARE Prime Overseas
• TRICARE Select Overseas

* Please see the Section 3.1 table that provides a summary of the TRICARE plans administered by TriWest for the West Region.

For more information about TAMP, visit TRICARE’s Transitional Assistance Management Program webpage.

Transitional Care for Service-Related Conditions Program (TCSRC)

TCSRC extends TRICARE coverage to former active duty, Guard, and Reserve members for certain service-related conditions beyond their regular 180-day TAMP coverage period. The benefit is available worldwide.

Beneficiaries that are eligible for TAMP and have a newly diagnosed medical condition related to active duty service may qualify for TCSRC if the beneficiary’s medical condition is:

• Service-related
• Newly discovered or diagnosed during the 180-day TAMP period
• Able to be resolved within 180 days
• Validated by a DOD physician

Once the DOD validates a medical condition eligible for TCSRC, the beneficiary’s coverage will show in DEERS.

To get started, beneficiaries should follow the instructions found on the TCSRC webpage. These instructions include:

• Preparing a letter requesting coverage
• Collecting copies of documents showing the condition is service-related
• Completing the TCSRC Application Worksheet
• Completing the Provider Checklist & Instructions
• Submitting the letter and completed Application Worksheet

Beneficiaries should mail the letter and completed Application Worksheet and all other supporting documentation to the address found on the TCSRC webpage.

Continued Health Care Benefit Program (CHCBP)

CHCBP is a premium-based health care program that offers temporary transitional health care coverage for 18-to-36 months after the TRICARE eligibility ends and acts as a bridge between military health care benefits and the beneficiary’s new civilian health care plan. It provides the same coverage as TRICARE Select, including prescriptions. It also gives the beneficiary minimum essential coverage as required by the Affordable Care Act.

For more information on eligibility, see the CHCBP webpage.

Humana Military is the CHCBP contractor, providing enrollment, authorization, claims processing, and customer service services. For more information about CHCBP or to see if a beneficiary qualifies:

• Visit Humana’s CHCBP website
• Call Humana Military at 1-800-444-5445

TRICARE Specialty Programs

TRICARE Extended Care Health Option (ECHO)

ECHO aids eligible beneficiaries with special needs for an integrated set of services and supplies beyond those offered by the basic TRICARE programs (e.g., Prime, TPR, Select).

Potential ECHO beneficiaries must first be enrolled in the Exceptional Family Member Program (EFMP) through the sponsor’s branch of service to receive ECHO benefits. Under certain circumstances, this requirement may be waived. Beneficiaries can be referred to this program online in the secure provider portal or providers can call our dedicated ECHO phone line (833) 818-2402 and select the ECHO option to begin the registration process.

The following beneficiaries who are diagnosed with a moderate or severe intellectual disability, a serious physical disability, or an extraordinary physical or psychological condition may qualify for ECHO:

• ADFMs
• Family members of activated National Guard/Reserve members
• Family members covered under TAMP
• Children or spouses of former Service members who are victims of abuse and qualify for the Transitional Compensation Program
• Family members of deceased active duty sponsors while they are considered “transitional survivors”

The qualifying family member’s disability must be entered properly in DEERS to access ECHO services.

Children may remain eligible for ECHO beyond the usual age limits in some circumstances. Beneficiaries may call the dedicated ECHO line (833) 818-2402 and select the ECHO option to determine eligibility for ECHO benefits if they believe a qualifying condition exists.

ECHO Benefits

ECHO benefits can include:

• Training
• Rehabilitation
• Special education
• Assistive technology devices
• Institutional care in private non-profit, public, and state facilities (may include transport to and from)
• Home health care
• Respite care for the primary caregiver

Some services may be cost-shared under ECHO or the beneficiary’s basic TRICARE program. This includes services needed to establish or confirm the severity of a qualifying condition or measure functional loss. For more information, visit the ECHO benefits webpage.

Additional ECHO benefits include ECHO Home Health Care (EHHC) and Respite Care for Primary Caregivers. Beneficiaries must use resources such as public funds and other programs if they are available in their communities. These resources include training, rehabilitation, special education, assistive technology devices, and institutional care in private nonprofit, public, and state facilities (may include transport to and from). If these resources are not available or sufficient, beneficiaries may request ECHO benefits by providing a Public Facility Use Certificate along with an explanation of why the resources are not available or sufficient.

ECHO Costs

There are no enrollment fees for ECHO benefits, but beneficiaries must pay a monthly copayment based on the sponsor’s pay grade. This information can be found on the ECHO Costs and Coverage Limits webpage.

The coverage limit for the cost of combined ECHO services (excluding EHHC, see section 3.3.3.3) is $36,000 per beneficiary per calendar year. Costs cannot be shared between family members.

Coverage for the EHHC benefit is capped annually and limited to the maximum fiscal amount TRICARE would pay if the beneficiary resided in a skilled nursing facility. This amount is based on the beneficiary’s geographic location.

For more information about TRICARE ECHO, refer to the TRICARE Policy Manual (TPM), Chapter 9 or see the Extended Care Health Option Fact Sheet.

ECHO Home Health Care Benefits

The EHHC benefit provides services or respite care to those ECHO-registered beneficiaries who:

• Are homebound
• Require skilled services beyond the coverage level that TRICARE Home Health Care Prospective Payment System provides
• Require frequent interventions that their primary caregiver normally provides
• Have a case manager who periodically assesses their needs and required services
• Have a physician-certified plan of care that details the services that are provided

Beneficiaries must obtain a referral or prescription before obtaining certain EHHC services. TRICARE Prime beneficiaries should contact their PCM and TRICARE Select beneficiaries should contact their family provider/primary care physician who will then:

• Decide eligibility for EHHC services
• Develop a plan of care

The physician, case manager, and/or TriWest must review the beneficiary’s plan every 90 days or when there is a change in condition.

Respite Care

The EHHC respite care benefit provides a maximum of eight hours per day up to five days per week to give primary caregivers time to rest/temporary relief. EHHC cannot be used for child care services, sibling care, employment, deployment, or when pursuing education. It also cannot accumulate if unused. Only one respite care benefit (ECHO respite or EHHC respite) can be used in the same calendar month.

EHHC Benefit Cap

EHHC benefit coverage caps out on an annual basis and the amount is determined by the beneficiary’s geographic location. TRICARE coverage caps at the maximum amount TRICARE would pay if the beneficiary resided in a skilled nursing facility.

For more information about EHHC, visit the EHHC webpage.

Autism Care Demonstration

The Autism Care Demonstration (ACD) provides TRICARE reimbursement for Applied Behavior Analysis (ABA) services to TRICARE-eligible beneficiaries diagnosed with autism spectrum disorder (ASD). To qualify for ACD, beneficiaries must be enrolled in a TRICARE plan option and have a definitive ASD diagnosis from an approved ASD diagnosing provider (PCM or a specialized ASD diagnosing provider).

TriWest’s online ACD provider directory includes ABA providers, parent-mediated programs, ASD diagnosing providers, respite care, speech language pathologist (SLP), OT, PT, etc.

Dependents of ADSMs diagnosed with ASD must be enrolled in the Exceptional Family Member Program (EFMP) and registered in ECHO.

ACD program steps are available on the ACD webpage. Assistance is available via the ACD information line at (833) 818-2525.

An Autism Services Navigator (ASN) is assigned to new beneficiaries and acts as a primary care coordinator. The ASN collaborates with the family and involved care providers to develop the Comprehensive Care Plan (CCP), to include setting goals, tracking timelines, connecting the beneficiary/family with clinical and non-clinical resources, and providing discharge, relocation, or transition support. The initial CCP shall be completed within 90 calendar days of the ASN assignment. For CCPs not completed within 90 calendar days as a result of family/beneficiary noncompliance, ASN and applicable ABA services shall be suspended through the duration of the existing authorization or until the CCP is complete, whichever comes first.

The ASN will ensure outcome measures are completed and submitted at baseline and by the respective repeated intervals (see TOM Chapter 18, Section 3, Paragraph 6.3) for:

• Pervasive Developmental Disorder Behavior Inventory (PDDBI) (6 months)
• Parental Stress Index (PSI) (6 months)
• Stress Index for Parents of Adolescents (SIPA) (6 months)
• Vineland Adaptive Behavior Scales (Vineland) (annual)
• Social Responsiveness Scale (SRS) (annual)

ABA providers are required to adhere to the following requirements of TOM Chapter 18, Section 3:

• Hold a bachelor's degree or higher in a relevant field recognized by the state licensure or certification authority. If no state licensure or certification is available, ABA providers must possess a degree in a field acknowledged by a DHA-approved certification organization.
• Maintain a valid, unrestricted state-issued license or state certification if they practice in a state that offers state licensure/certification. If no licensure/certification is offered, ABA providers must obtain state certification from either Behavior Analyst Certification Board (BACB) or the Qualified Applied Behavior Analysis (QABA).
• Complete ABA Provider Requirements pertaining to Certification/Credentialing including a training for Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification (see TOM Chapter 18, Section 3, Paragraph 8.2)
• Participate in medical team conferences coordinated by the ASN
• Comply with and participate in any corrective action required based upon the following required audits (see TOM Chapter 18, Section 3, Paragraph 8.9):
  • Clinical and non-clinical documentation audits
  • Audits related to insufficient clinical documentation to review medical record documentation progress
• Documentation Requirements
  • Meet all ABA Service Documentation requirements (TOM Chapter 18, Section 3 Paragraph 8.7)
    • Complete ABA Assessments and Treatment Plan (TP) documentation
    • Provide complete progress note documentation
  • Provide medical records to support (TOM Chapter 18, Section 3 Paragraph 8.9.7)
    • Ensuring session documentation notes comply with all requirements
    • Correcting insufficiencies when identified by TriWest
  • ASCP/Sole Provider groups will have a minimum of 30 records audited on an annual basis which includes a combination of administrative records and medical documentation review, and one medical team conference session note.
    • TriWest will conduct outreach and education to the ASCP/Sole Provider group with inconsistencies or errors identified in the audits. Additionally, TriWest will initiate progressively more severe administrative action, commensurate with the seriousness of the identified problems, consistent with TOM Chapter 13, and 32 CFR 199.9.
    • All claims determined to be insufficient for claims payment, if already paid, shall be recouped.
  • Follow timeline and authorization requirements for:
    • ABA services (see TOM Chapter 18, Section 3, Paragraph 8.6.2)
      • Complete initial assessment and develop TP, including recommended Adaptive Behavior Treatment Current Procedural Terminology (CPT) code and number of units
    • Subsequent referrals and authorizations (see TOM Chapter 18, Section 3, Paragraph 8.6.3)
      • For clinically indicated ongoing services, submit re-authorizations for ABA services before the expiration of each six-month treatment authorization period, as early as 60 calendar days in advance, but no later than 30 calendar days in advance
    • Submit only authorized CPT codes and their units (see TOM Chapter 18, Section 3, Paragraph 8.11.6 for ACD Approved CPT Codes)
    • Submit claims electronically and comply with reimbursement rates provided in TOM Chapter 18, Section 3, Paragraph 8.11.7)

Exclusions/non-covered services under the ACD include (See TOM Chapter 18 Section 3 paragraph 8.10 for a full list.):

• Behavior Technicians (BTs) training
• ABA services for any other diagnoses other than ASD
• ABA services are not covered for symptoms and/or behaviors that are not part of the ASD core symptoms (i.e., impulsivity due to ADHD, reading difficulties due to learning disability, excessive worry due to anxiety disorder)
• Billing of direct and indirect supervision of BTs and assistant behavior analysts
• Billing for emails and phone calls
• Billing for mileage and drive time to and from ABA services appointments (i.e., beneficiary’s house, clinic, or other locations).
• Rendering and billing for ABA services involving any aversive techniques or restraints
• Rendering and billing for custodian, personal care, and/or child care
• Billing for office supplies to include therapeutic supplies
• Billing for report writing outside of what is included in assessment CPT code 97151
• Educational/academic and vocational ABA services; all educational/academic and vocational goals must be removed from the treatment plan before approval
• TRICARE will authorize and reimburse only CPT code 97153 rendered by the authorized ABA supervisor (not delegated to the assistant or BT) in the school setting
• Authorizations for BTs in a school setting will not be approved
• Autism schools are not TRICARE-authorized providers. If an autism school has a clinic setting as part of their offered services, the clinic must have a separate tax identification number (TIN) and is not owned by the child’s responsible adult.
• Rendering or billing for any two ABA providers at the same time under one CPT code

Please review the ACD policy (TOM Chapter 18 Section 3) in its entirety for complete overview of TRICARE requirements to be a TRICARE-authorized provider and provide ACD services.

TRICARE Provider Types

TRICARE defines a provider as a person, business, or institution that provides health care. Beneficiaries must use TRICARE-authorized providers that are licensed by a state for independent practice, accredited by a national organization, or meet other standards of the medical community. For more information on provider types, refer to chart of provider types at tricare.mil/. TriWest contracts with network providers in the West Region to deliver health care to TRICARE beneficiaries.

TRICARE Authorized Providers. Sec. 199.6 of the Title 32 National Defense Manual describes requirements for TRICARE providers and suppliers. This manual sets forth general policies and procedures that are the basis for the CHAMPUS cost-sharing of medical services and supplies provided by institutions, individuals, or other types of providers. Providers seeking payment from the federal government through programs such as CHAMPUS have a duty to familiarize themselves with, and comply with, the program requirements.

TRICARE-authorized providers must meet state licensing and certification requirements and are authorized by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, urgent care centers, ancillary providers (nurse practitioners, physician assistants, and physical therapists), laboratory and radiology providers, and pharmacies.

TRICARE-authorized providers do not include any provider type not specifically named in TPM Chapter 11. For providers in TriWest's Community Care Network (CCN) provider network for VA, please note that there are differences between the contracts. Beneficiaries are responsible for the full cost of care if they see providers who are not TRICARE-authorized.

Primary Care Managers

In TRICARE Prime, PCMs coordinate care for beneficiaries assigned as their patients and provide all non-emergency care within their capabilities. PCMs are responsible for maintaining beneficiary medical records and referring beneficiaries for urgent, emergent, and specialty care outside of their capabilities. This includes working with TriWest to obtain referrals and prior authorizations.

PCMs can be a part of an MTF or a civilian network provider. The following provider specialties are eligible to serve as PCMs in TRICARE:

• General practice
• Family practice
• Internal medicine
• Pediatrician
• Obstetrician/gynecologist
• Physician assistant
• Nurse practitioner
• Certified nurse midwife

PCMs are selected by TRICARE Prime beneficiaries at enrollment. TRICARE Prime beneficiaries must seek all non-emergency services from their PCM and obtain referrals to other providers before obtaining services.

PCMs are responsible for:

• Primary care services
• Following TRICARE procedures for obtaining necessary prior authorizations and referrals for non-emergency care
• Providing access to care 24 hours a day, seven days a week (including after-hours and urgent care services) or arrange for on-call coverage by another PCM
• Maintaining beneficiary medical records, including from referrals and emergency care
• Notifying TriWest of changes in capacity

During the performance of the contract, TriWest will adjust PCM enrollment capacity based on claims history and PCM feedback.

Behavioral Health Providers

The TRICARE behavioral health care outpatient network consists of TRICARE-authorized providers, such as:

• Advanced Practice Nurses
• Applied Behavior Analysis (ABA) licensed/certified providers
• Board Certified Behavior Analysts (BCBA)
• Board Certified Behavior Analysts-Doctoral (BCBA-D)
• Certified Clinical Social Workers
• Certified Marriage and Family Therapists (e.g., Licensed Professional Counselor, Licensed Marriage and Family Therapist (LMFT))
• Certified Psychiatric Nurse Specialists (CPNS)
• Clinical Psychologists
• Licensed Psychological Associates
• Psychiatrists and other Physicians
• Substance Abuse Counselors (e.g., Licensed Clinical Alcohol & Drug Abuse Counselor [LCDAC])
• Supervised Behavioral Health (BH) Counselors
• Supervised Licensed Pastoral Counselors TRICARE-Certified Mental Health Counselors (TCMHC)

To be a TRICARE-authorized provider and deliver care under the TRICARE program, providers must:

• Meet professional licensing and certification requirements for independent practice, with the exception of Supervised Behavioral Health Counselors and Supervised Licensed Pastoral Counselors TRICARE-Certified Mental Health Counselors.
• Be certified by TRICARE
• Be licensed in the jurisdiction where they provide care (Title 32, Code of Federal Regulations, Part 199.6)

Behavioral Health Care Network

The TRICARE behavioral health care network consists of:

• Hospitals
• Inpatient psychiatric units
• Opioid treatment programs (OTP)
• Substance use disorder rehabilitation facilities (SUDRF)
• Partial hospitalization programs (PHP)
  • A TRICARE-authorized psychiatric PHP can be a distinct part of an otherwise TRICARE-authorized institutional provider or a freestanding program.
  • For TRICARE certification, the PHP must be currently accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the DHA Director.
  • For acute care hospital-based PHPs, when a hospital is a TRICARE-authorized provider, the hospital’s PHP is also considered a TRICARE-authorized provider.
• Intensive outpatient programs (IOP)
  • A TRICARE-authorized psychiatric IOP can be a distinct part of an otherwise TRICARE-authorized institutional provider or a freestanding program.
  • For TRICARE certification, the IOP must be currently accredited by TJC, CARF, CoA, or an accrediting organization approved by the DHA Director.
  • For acute care hospital-based IOPs, when a hospital is a TRICARE-authorized provider, the hospital’s IOP is also considered a TRICARE-authorized provider.
• Residential treatment centers (RTC)
  • Must be currently accredited by TJC, CARF, CoA, or an accrediting organization approved by the DHA Director.
  • Must be licensed as an RTC to provide RTC services within the applicable jurisdiction in which it operates.
  • For more specific information regarding RTC standards, refer to the TRICARE Policy Manual Chapter 11.

To become a network provider, these facilities must complete the TriWest contracting process, unless the facility is a VA facility. These facilities must sign a participation agreement to comply with all TRICARE policies before rendering services to TRICARE beneficiaries.

For information regarding PHPs, IOPs, RTCs, OTPs, and SUDRFs, refer to the TRICARE Policy Manual Chapter 11.

Corporate Services Provider Class (CSP)

The CSP class comprises of institutional-based or freestanding corporations and foundations that render principally professional, ambulatory, or in-home care and technical diagnostic procedures. However, CSPs cannot be a professional corporation or professional association. A professional corporation is a form of corporation authorized by state statute for a specified list of licensed professions, often including doctors, lawyers, public accountants and engineers. State law defines a professional association. State law must be consulted for a determination of whether the entity is considered a professional corporation or professional association.

The provider types in this category may include:

• Cardiac catheterization clinics
• Comprehensive outpatient rehabilitation facilities
• Diabetic outpatient self-management education programs (American Diabetes Association accreditation required)
• Freestanding bone-marrow transplant centers
• Freestanding Magnetic Resonance Imaging (MRI) centers
• Freestanding sleep-disorder diagnostic centers
• Home health agencies (pediatric or maternity management required)
• Home infusion (Accreditation Commission for Healthcare accreditation required)
• Independent physiological laboratories
• Radiation therapy programs

For more information about Corporate Services Provider reimbursement, refer to TPM, Chapter 11, Section 12.1.

TRICARE Medical Coverage

TRICARE medical coverage details can be found on the TRICARE Types of Care website and in the TRICARE Policy Manual. Additional program information is included in the following sections.

Primary Care

TRICARE defines primary care as the initial medical care given by a health care provider to a patient, especially as part of regular ambulatory care, and sometimes followed by referral to other medical providers.

In TRICARE Prime, PCMs coordinate care for beneficiaries assigned as their patients and provide all non-emergency care within their capabilities. TRICARE Prime beneficiaries must seek all non-emergency services from their PCM, obtaining referrals to other providers before obtaining services. For more information, please reference the Primary Care Managers (PCM) subsection of this document.

Covered primary care services may include, but are not limited to:

• Asthma testing and treatment
• Blood pressure screening
• Body measurement
• Cardiovascular screening
• Pediatrics
• Certain physicals

Preventive Care

Preventive care services include diagnostic and other medical procedures not related directly to a specific illness, injury, or definitive set of symptoms, or obstetrical care, but rather performed as periodic health screening, health assessment, or health maintenance. Covered preventive care services are applicable to beneficiaries 6 years of age or older.

Per TRICARE Policy Manual Chapter 7, Section 2.2, TRICARE Prime enrollees may receive Prime clinical preventive services from any network provider within their geographic area of enrollment without a referral or authorization. If a TRICARE Prime clinical preventive service is not available from a network provider (e.g., a network provider is not available within prescribed access parameters), an enrollee may receive the service from a non-network provider with a referral from the PCM and authorization from the TriWest.

Covered preventive care services include but are not limited to:

• Cancer screening examinations and services
• Immunizations
• Health promotion and disease prevention (HP&DP) examinations
• Well Woman examinations
• Routine eye examinations
• Audiology screening

For more information, please refer to the TRICARE Policy Manual Chapter 7 Section 2.1 and TRICARE Policy Manual Chapter 7 Section 2.2.

Specialty Care

Specialty care is defined as specialized medical/surgical diagnosis, treatment, or services performed by a physician specialist that a PCP is not qualified to provide. In TRICARE Prime, a beneficiary’s PCM refers to specialists for care they cannot provide. In TRICARE Select, referrals are not required for specialist providers. However, some services require prior authorization.

To determine if a specific service is a covered benefit or if referral/authorization is required, use the Referral and Authorization Decision Support (RADS) tool.

Behavioral Health

TRICARE covers services delivered by qualified, TRICARE-authorized behavioral health care providers practicing within the scope of their licenses, to diagnose and/or treat covered behavioral health disorders.

Only the types of providers listed in TRICARE Policy Manual, Chapter 11, Sections: 3.6-3.11 are considered qualified providers of behavioral health services. All services and supplies provided by unauthorized providers or not considered medically or psychologically necessary are generally excluded. For information about the requirements for being a TRICARE-authorized provider, refer to the TRICARE Policy Manual, Chapter 11, Sections: 3.6-3.11.

According to TPM Chapter 7, Section 3.7 covered conditions must:

• Involve a clinically significant behavioral or psychological syndrome or pattern that is associated with a painful symptom, such as distress, and that impairs a patient’s ability to function in one or more major life activities.
• The condition must be one of those conditions listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

To determine if a specific service is a covered benefit or if coverage is limited, use the Referral and Authorization Decision Support (RADS) tool.

Incident Reporting

All serious occurrences involving a TRICARE beneficiary while receiving services at a TRICARE-authorized treatment program (e.g., RTC, freestanding PHP, or SUDRF) must be reported to TriWest by phone at 1-888-TRIWEST (874-9378) within one business day.

Pre-Authorization and Referral Requirements

TRICARE pre-authorization and referral requirements vary according to beneficiary type, program option, diagnosis, and type of care. See the RADS tool or Prior Authorization List (PAL).

Clinical Documentation for Behavioral Health Care Services

TRICARE providers must keep sufficient clinical records to substantiate that care provided was actually and appropriately furnished and was medically or psychologically necessary.

Behavioral health care provider types must, at a minimum, maintain medical records in accordance with TJC, CARF, CoA, or an accrediting organization approved by the DHA Director.

Acceptable clinical documentation may include, but is not limited to:

• Psychiatric and psychological evaluations
• Physician orders
• Treatment plans
• Physician and/or integrated progress notes
• Discharge summaries

Standardized Measures

All behavioral health care settings must include assessments at treatment baseline, every 60-day intervals, and at discharge using the following standardized measures in the evaluation report for the following diagnosis:

• Post-Traumatic Stress Disorder (PTSD): PTSD Checklist (PCL-5)
• Anxiety Disorders: Seven-Item Generalized Anxiety Disorder (GAD-7)
• Depressive Disorders: Patient Health Questionnaire 9 (PHQ-9 or A for ages 11-17)

All providers participating in ACD care settings must clearly report scores for completed and valid outcome measures at treatment baseline (varies per assessment – see below) using the most current published version of the following standardized outcome measures in the treatment plan:

• Parenting Stress Index (PSI) ages 0-12, at baseline and every six months
• Stress Index for Parents of Adolescents (SIPA) for ages 11-19, at baseline and every six months
• Vineland Adaptive Behavior Scales (Vineland) at baseline and annually
• Social Responsiveness Scale (SRS) annually
• Pervasive Development Disorder Behavior Inventory (PDDBI) including all domain and composite scores, at baseline and every six months

According to TPM Chapter 11, Section 12.3, Providers must notify the referring MTF when a TRICARE beneficiary in the provider’s clinical judgment meets any of the following criteria:

• Is a potential harm to self – The provider believes there is a serious risk of self-harm by the Service member either as a result of the condition itself or medical treatment of the condition.
• Is a potential harm to others – There is a serious risk of harm to others either as a result of the condition itself or medical treatment of the condition. This includes any disclosures concerning child abuse or domestic violence.
• Is a potential harm to mission – There is a serious risk of harm to a specific military operational mission. Such a serious risk may include disorders that significantly impact the beneficiary’s impulsivity, insight, reliability, and judgment.
• Is admitted or being discharged from any inpatient behavioral health or SUDRF.
• Is experiencing an acute medical condition or engaged in an acute medical treatment regimen that impairs the beneficiary’s ability to perform assigned duties.
• Has entered or is being discharged from an inpatient and outpatient Substance Use Disorder (SUD) programs.

Non-Covered Conditions and Treatment

A complete list of behavioral health care services that are excluded under TRICARE are provided on the TRICARE Mental Health Exclusions webpage. Before delivering care, network providers must notify TRICARE beneficiaries if services are not covered. The beneficiary must agree in advance in writing to receive and accept financial responsibility for non-covered services by signing a Request for Non-Covered Services.

To obtain specific information on TRICARE policy, benefits and coverage, please consult the TRICARE Policy Manual, TRICARE Reimbursement Manual, or the code look-up feature on the RADS tool.

Maternity Care

Maternity care includes the medical services related to conception and delivery as defined on the TRICARE Maternity (Pregnancy) Care webpage and TRICARE Policy Manual (TPM) Chapter 4, Section 18.1.

TRICARE covers all medically necessary pregnancy care with limitations, including prenatal care, post-partum care (generally for six weeks after delivery), and treatment of any complications.

TRICARE Prime (TRICARE Prime, TPR, TRICARE Young Adult Prime) beneficiaries require a referral from TriWest for civilian professional maternity care services (e.g., obstetrician, gynecologist, or nurse midwife). The approved referral for Global OB care starts with the initial prenatal visit and remains valid through postpartum care, generally six weeks after the infant’s birth. It includes the hospital admission for a routine delivery. Hospital inpatient admission and birthing center delivery require notification to TriWest within 24 hours of admission or the next business day.

TRICARE Select beneficiaries can obtain all maternity care without a pre-authorization or referral from TriWest.

Birthing care centers must be TRICARE-certified.

See TPM Chapter 8, Section 2.6 and our TriWest Quick Reference Guides for information on breast pumps and supplies and breastfeeding counseling.

To obtain specific information on TRICARE benefits and coverage, please consult the RADS tool.

Telemedicine

TRICARE covers telemedicine visits including secure video conferencing and audio-only (using a computer or a smartphone) through a secure connection with a beneficiary’s provider. Beneficiaries pay cost-shares and copayments for telemedicine visits. TRICARE covers the following telemedicine visits:

• Office visits
• Preventive health screenings
• Telemental health services
  • A referral for telemental health services is required, more information can be found on the Telemental Health Services webpage.

Beneficiaries can contact TriWest for a referral or pre-authorization for telemedicine visits, including telemental health services.

Audio-only telemedicine for TRICARE for Life (TFL) beneficiaries should be covered by Medicare. If not, TFL is the first payer. Refer to the Medicare homepage for information on Medicare coverage.

Refer to the Telemental Health Services webpage and TRICARE Policy Manual (TPM), Chapter 7, Section 22.1 for more information on TRICARE’s telemedicine benefit.

Originating Sites

TriWest monitors originating site location coverage across the TRICARE West Region. Originating site coverage is assessed through evaluation of our provider partners against Health Professional Shortage Areas (HPSA) and examination of provider locations submitting claims with the originating site CPT code (i.e., Q3014). This allows TriWest to determine where originating site location gaps exist so we can develop targets to expand access.

Provider-to-Provider Teleconsultations

TriWest providers can request provider-to-provider teleconsultations for challenging cases from expert specialists at institutions with nationally recognized specialty-specific accreditation in the appropriate medical field that are participating in the TriWest network (a “Consulting Provider”). Providers seeking a teleconsultation may use the TRICARE West provider directory to identify a Consulting Provider.

When a Consulting Provider offers asynchronous teleconsultation to another provider in the TriWest network, the following shall apply:

• The Consulting Provider must provide a response within one business day,
• The response must capture whether the Consulting Provider recommended a referral, and
• The consulting provider must provide synchronous technical assistance (as needed) during business hours.

Providers must use secure HIPAA-compliant communication methods to undertake any teleconsultation. All Providers are expected to follow the claims submission process when teleconsultations are performed, leveraging applicable CPT codes (i.e., 99446, 99447, 99448, 99449, 99452, 99451).

Provider Requirements

TriWest ensures providers follow all telemedicine-specific regulatory, licensing, credentialing and privileging, malpractice/insurance laws, and compliance with required regulatory and accrediting agencies, in accordance with the TRICARE Policy Manual, Chapter 7, Section 22.1. Providers must:

• Follow professional discipline and national practice guidelines when practicing via telemedicine. Any modifications to applicable clinical practice guidelines for the telemedicine setting shall ensure that clinical requirements specific to the discipline are maintained.
• Make arrangements for handling emergency situations at the outset of treatment to ensure consistency with established local procedures
  • For behavioral health services, this should include the processes for hospitalization or civil commitment within the jurisdiction where the patient is located if necessary.
• Implement means for verification of provider and patient identity for synchronous telemedicine services.
  • For telemedicine services where the originating site is an authorized institutional provider, the verification of both professional and patient identity may occur at the host facility.
  • For telemedicine services where the originating site does not have an immediately available health professional (e.g., the patient’s home), the telemedicine provider provides the patient (or legal representative) with the provider’s qualifications, licensure information, and, when applicable, registration number (e.g., National Provider Identifier) and the patient provides two-factor authentication.
• Document provider and patient location in the medical record as required for the appropriate payment of services for synchronous telemedicine services.
  • Documentation includes elements such as city/town, state, and ZIP code (or country for overseas services).
• Ensure that transmission and storage of data associated with asynchronous telemedicine services is conducted over a secure network and is compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements.
• Establish an alternate plan for communicating with the patient (e.g., telephone) in the event of a technological breakdown/failure.
  • This should be developed at the outset of treatment. In order for the telemedicine services to resume, all technological requirements of this policy must be restored, as telemedicine cannot be performed by telephone services alone.
• Apply HIPAA privacy and security requirements for the use and disclosure of Protected Health Information (PHI) to all telemedicine services.

Reimbursement for Telemedicine – Distant Site

For TRICARE payment to be authorized, the provider must be a TRICARE-authorized provider and the service must be within a provider’s scope of practice under all applicable state(s) law(s) in which services are provided and or received. Telemedicine services are subject to the same authorization/referral requirements. Beneficiaries can contact TriWest for a referral or pre-authorization for telemedicine visits, including telemental health services.

Beneficiaries are responsible for any applicable copay or cost-share.

For technical requirements, connectivity, privacy and security, and other issues, refer to the TRICARE Policy Manual, Chapter 7, Section 22.1.

Emergency Care

TRICARE covers emergency care, including professional and institutional charges, services, and supplies that are ordered/administered in an emergency department. Emergency care is care for an illness or injury that is threatening to life, limb, sight, or safety and requires immediate medical attention.

Examples of conditions that require emergency care include:

• No pulse
• Severe bleeding
• Spinal cord or back injury
• Chest pain
• Severe eye injury
• Broken bone
• Inability to breathe

A medical emergency includes the sudden and unexpected onset of a medical condition or the acute exacerbation of a chronic condition that is life, limb, or eyesight threatening, requires immediate medical treatment, or manifests painful symptoms requiring immediate response to alleviate suffering.

This also includes pregnancy-related medical emergencies that involve sudden and unexpected medical complications that put the mother, the baby, or both at risk.

A psychiatric inpatient admission is an emergency when, based on a psychiatric evaluation performed by a physician (or other qualified behavioral health care professional with hospital admission authority), the beneficiary is at imminent risk of serious harm to self or others due to a behavioral disorder and requires immediate continuous skilled observation at the acute level of care.

To avoid penalties, providers must notify TriWest of any emergency admission using Availity online within 24 hours or by the next business day following admission and discharge. TriWest reviews admission information and authorizes continued care, if necessary. Please refer to the TRICARE Referrals and Authorizations section for more information.

TRICARE Prime beneficiaries must obtain all non-emergency primary health care from their PCM or from another provider to which the beneficiary is referred by the PCM or TriWest. If a TRICARE Prime beneficiary seeks treatment in an Emergency Department and there wasn’t a referral by the PCM, and it is clearly a case of routine illness where the beneficiary’s medical condition never was, or never appeared to be an emergency, the beneficiary may be responsible for paying Point of Service (POS) fees.

If a beneficiary requires emergency care, direct the beneficiary to call 911 or to go to the nearest emergency room.

Urgent Care

TRICARE covers urgent care for medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately but does require attention before it becomes a serious risk to health.

Examples of serious conditions (but not life-threatening) that should receive urgent treatment include:

• Sprains
• Scrapes
• Ear aches
• Sore throats
• A raised temperature

Urgent Care for TRICARE PRIME – Active Duty Service Members

According to the TRICARE Operations Manual, Chapter 7, Section 5, Paragraph 2.1, ADSMs enrolled in TRICARE Prime require a referral from the MTF provider or through the MHS Nurse Advice Line (NAL). ADSMs enrolled to the TRICARE Overseas Program (TOP) or in TRICARE Prime Remote (TPR) do not need an urgent care referral, but they are still held to applicable DOD and Service requirements concerning authorization for private sector care.

TRICARE Prime’s POS option does not apply to ADSMs, who may be responsible for the entire cost of their care if they seek urgent care without a referral when required.

Urgent Care for Other Beneficiaries

The following beneficiaries do not require a referral or authorization before seeking any urgent care services from a network or non-network provider, in accordance with TRICARE Operations Manual, Chapter 7, Section 5.0; however, out-of-pocket costs may be more when seeking services from non-network providers:

• TRICARE Select
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Young Adult (Prime and Select)

These beneficiaries may self-refer for urgent care from a TRICARE network provider or a TRICARE-authorized (network or non-network) urgent care center (UCC) or convenience clinic (CC). If the enrollee seeks care from a non-network provider, the usual POS deductible and cost-shares shall apply.

Nurse Advice Line

Beneficiaries may contact the Nurse Advice Line 24 hours a day, seven days a week, 365 days per year at 1-800-TRICARE (874-2273). Registered nurses are available to help beneficiaries:

• Answer urgent care questions
• Give health care advice
• Help find a doctor
• Schedule next-day appointments at military hospitals and clinics

All TRICARE beneficiaries can access the Nurse Advise Line in the U.S. except those enrolled in the US Family Health Plan (USFHP). Beneficiaries who live overseas can call the Nurse Advice Line when traveling in the U.S., but must coordinate care with their Overseas Regional Call Center.

Home Infusion Therapy

TRICARE covers home infusion therapy. Home infusion therapy is a limited benefit that covers medicine taken in the home in a way other than swallowing, including:

• A shot in the muscles
• Injection beneath the skin
• Injection through veins
• Infused through a piece of Durable Medical Equipment (DME)

The medication type and length of administration determines whether the home infusion/injection medication will be paid by TriWest under the TRICARE medical benefit or by Express Scripts® through the TRICARE pharmacy benefit. Providers can use the RADS tool to determine if it is covered as a TRICARE medical benefit through TriWest.

Home infusion therapy requires pre-authorization from TriWest for all beneficiaries, except those with other health insurance (OHI) and when TRICARE is not the primary payer.

For more information, refer to TRICARE Policy Manual, Chapter 8, Section 20.1.

Hospitalization

TRICARE covers hospitalization services, including:

• Emergency services
  • Medical or psychiatric emergency
  • Immediate hospital admission
  • Mental health or SUD services include:
    • Management of withdrawal symptoms (detoxification)
    • Stabilization
    • Medical complications from the disorder
  • Non-emergency services
    • Inpatient psychiatric hospitalization
      • Diagnosis and treatment of mental health
      • SUD

All scheduled hospitalizations require pre-authorization. For non-emergency inpatient psychiatric services, care may be provided in private psychiatric hospitals or local, state, or federal government psychiatric hospitals.

Inpatient psychiatric services may receive an approval if the beneficiary:

• Poses a serious risk of harm to themselves or others
• Needs specialized medication
• Needs psychological treatment
• Has a significant impairment in functioning
• Needs to be in a hospital full-time
• Is unable to maintain themselves in the community with only outpatient services

Skilled Nursing Facility Care

Per TOM Chapter 7, Section 4, Skilled Nursing Facility (SNF) care must be preauthorized for all TRICARE beneficiaries to include dual eligible beneficiaries. For a SNF admission to be covered under TRICARE, the beneficiary must have a qualifying hospital stay of three consecutive days or more, not including the hospital discharge day, and the beneficiary must enter a Medicare-certified, TRICARE-participating SNF within 30 calendar days of discharge from the hospital. TRICARE has also adopted Medicare’s Interrupted Stay Policy for SNF admission. For more information, please see TRM Chapter 8, Section 2.

There is no day limit while medical necessity continues.

Hospice Care

Beneficiaries may receive hospice care if they are terminally ill. Hospice care helps manage beneficiaries’ pain and symptoms, while helping them live as comfortably as possible. The benefit covers supportive services including pain control and counseling services, home health aide services, and personal comfort items.

Hospice care services require:

• A beneficiary to be referred for hospice care
• A beneficiary’s doctor to submit orders for hospice care
• A beneficiary to complete and give an election statement to a hospice provider
  • The provider must file the election statement with TriWest

Beneficiaries who receive hospice care cannot receive curative treatment related to the terminal illness unless hospice has been revoked. Beneficiaries under age 21 are eligible for medically necessary curative treatment related to the illness in addition to palliative care.

TRICARE provides hospice care in three benefit periods:

• Period one: 90 days
• Period two: 90 days
• Period three:Unlimited 60-day periods

Beneficiaries need pre-authorization for each period and each 60-day period requires recertification of terminal illness.

Hospice levels of care include continuous home care, general hospice inpatient care, inpatient respite care, and routine home care. Types of care may include:

• Physician services
• Nursing care
• Counseling
• Medical equipment and supplies
• Medications
• Medical social services
• Physical and occupational services
• Short-term inpatient care
• Speech and language pathology

Hospice care requires pre-authorization from TriWest for all beneficiaries.

For more information about TRICARE’s hospice coverage refer to TRICARE Reimbursement Manual, Chapter 11, Section 3.

Laboratory, X-ray, and Laboratory Developed Test Services

TRICARE covers most laboratory and X-ray services that have been prescribed by a physician. There are certain exceptions for chemo-sensitivity assays and bone density X-ray studies for routine osteoporosis screening.

The Laboratory Developed Test (LDT) Demonstration Project allows TRICARE to review non-FDA approved LDTs to determine if they meet TRICARE requirements for safety and effectiveness according to the hierarchy of reliable evidence as referenced in TRICARE Operations Manual, Chapter 18 Section 2.

A LDT is an In Vitro Diagnostic (IVD) test that is designed, manufactured, and used within a single laboratory.

For an LDT to be considered for coverage, the beneficiary must meet the following criteria:

• Meet the test’s coverage guidelines
• Get pre-authorization from TriWest for all covered tests, except cystic fibrosis screening
• Get the test at an accredited clinical lab

LDT Authorization

Pre-authorization is required for all LDTs, except cystic fibrosis testing.

TriWest authorizes LDTs in accordance with the TRICARE Operations Manual, Chapter 18 Section 2. Providers who perform LDT procedures more than once for the same beneficiary should use the appropriate modifiers and the claim will be processed accordingly. Claims submitted without pre-authorization will be denied.

Durable Medical Equipment (DME)

TRICARE covers DME or DME Prosthetics, Orthotics, and Supplies (DMEPOS) when prescribed by a physician that:

• Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition
• Maximizes the patient’s function consistent with the patient’s physiological or medical needs
• Provides the medically appropriate level of performance and quality for the medical condition present
• Not otherwise excluded by the regulation and policy

If DME needs customization or repairs, TRICARE covers the following situations:

• Medically necessary customization or attachments to the DME to accommodate the medical disability when the physician has prescribed the equipment as medically necessary and appropriate
• Medically necessary covered accessories and attachments to a DME necessary to make the DME “serviceable” for a particular disability (e.g., a car lift that is a wheelchair accessory)
• Repairs to equipment that a beneficiary owns when needed to make the item serviceable
• Replacement of DME that a beneficiary owns when:
  • There is a change in the beneficiary’s physical condition.
  • There is accidental damage to the DME.
  • The DME is inoperative and cannot be repaired.
  • The U.S. Food and Drug Administration (FDA) has declared the DME adulterated.
• Duplicate items (those that serve the same purpose, but may not be an exact duplicate, i.e., a portable oxygen concentrator as a backup for a stationary oxygen generator) that are essential to provide a fail-safe, in-home, life-support system.

Items that are not covered under the TRICARE benefit include:

• DME for a beneficiary who is a patient in a facility that ordinarily provides the same DME item to its patients at no additional charge in the usual course of providing its services is excluded
• DME available to the beneficiary from a military hospital or clinic
• DME with deluxe, luxury, or immaterial features, that will increase the item’s cost to the government relative to a similar item without those features
• Routine periodic servicing, such as testing, cleaning, regulating, and checking, which the manufacturer does not require be performed by an authorized technician
• Duplicate items of otherwise allowable DME to be used solely as a back-up to currently owned or rented equipment
• Expendable items (e.g., incontinent pads, diapers, ace bandages, etc.)
• Non-medical equipment (e.g., humidifier, electric air cleaners, safety grab bars, etc.)

For more information, please reference TRICARE Policy Manual, Chapter 8, Section 2.1 and TRM Chapter 1, Section 11.

Upgraded DMEPOS (Deluxe, Luxury, and Immaterial Features)

An upgraded DE item, which otherwise meets the DE benefit requirement and is medically necessary, is covered if the prescription specifically states the medical reason why an upgrade is necessary. If the beneficiary prefers to upgrade a DE item, which otherwise meets the DE benefit requirements, the beneficiary will be solely responsible for the cost that exceeds the cost of what the Government would pay for the standard equipment. Refer to the TRICARE Policy Manual, Chapter 8, Section 2.1 and TRICARE Reimbursement Manual Chapter 1, Section 11 for more information.

DMEPOS Referral and Authorization Guidelines

Providers can use the TriWest RADS tool to look up codes to determine if a specific DME/DMEPOS is covered or if a referral or authorization is required.