Provider Information

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Provider Resources Privacy and Security TRICARE Provider Authorization and Certification TRICARE Credentialing Charging Administrative Fees Nondiscrimination Policy Office and Appointment Access Standards Specialty Care Responsibilities Opioid Safety Initiative (OSI) Medical Documentation: Clear and Legible Reports (CLR) Updating Provider Information Provider Contract Provisions

The following sub-sections contain important information for providers to acknowledge and follow to provide health care services to TRICARE beneficiaries under the TRICARE program.

Providers must comply with applicable TRICARE requirements. Network providers sign a contract with TriWest to comply with all TRICARE and TriWest rules, requirements, policies, and procedures (please refer to the section on TRICARE Policy Resources). This handbook is not all-inclusive and is intended to present an overview of TRICARE and TriWest policies and procedures. In the event of a conflict between the contract and this handbook, the contract provisions supersede the handbook provisions.

For current information on TRICARE policy, please refer to the Title 10 of the United States Code, Title 32 of the Code of Federal Regulations (CFR), and TRICARE Manuals: TRICARE Operations Manual (TOM), TRICARE Reimbursement Manual (TRM), and TRICARE Policy Manual (TPM).

Provider Resources

Availity

Availity has a strong national presence connecting two million providers to health plans nationwide. Availity works with other clearinghouses, across other health plans, and is accessible through our secure provider portal. Providers who already use Availity can use their existing log-in.

If a provider does not already have Availity, TriWest provides assistance to access this powerful tool. Through Availity, providers can:

  • Update provider and office information
  • Use the Availity Clinical Gateway Platform to deliver consultation reports and other clinical/medical documentation if they do not already have an existing electronic Health Information Exchange (HIE)
  • Access secure transactions, including claims status, authorizations, and pharmacy data
  • View communications regarding program updates, new training, and updated processes

TriWest has a full training program on Availity that utilizes various training methods that walk providers through TriWest’s processes and procedures. The training methods include:

  • Webinars – live, interactive virtual classes where providers can ask questions in real time
  • Microlearning videos – short, bite-sized video snippets that cover various aspects of TRICARE
  • eSeminar Learning Paths – Microlearning based on a variety of topics that, when viewed consecutively, form a complete eSeminar; think of microlearning as individual songs and the Learning Path as the playlist

Providers may contact Availity for basic user support and questions regarding HIE. Please visit www.availity.com or call Availity at 800-282-4548.

Electronic Health Information Exchange (HIE)

We know many providers have existing HIEs. During credentialing, we will confirm that a provider’s HIE is compatible with the HIE the Defense Health Agency (DHA) utilizes.

If a provider does not already have a HIE, we can help them establish one.

Cultural Training

TriWest encourages providers to complete cultural training courses. Mental health care providers who have earned the DOD TRICARE Provider Readiness Designation (TPRD) as indicated by an icon, have knowledge of military culture and evidence-based treatments for mental health concerns common among members of the Armed Forces. To earn the TPRD, providers must complete the complete the six modules. Visit the TRICARE Provider Readiness Training | Center for Deployment Psychology to learn more about TPRD.

Privacy and Security

TriWest must ensure providers follow all privacy, security, and telemedicine-specific regulatory, laws, and rules for their profession in both the jurisdiction (site) in which they are practicing as well as the jurisdiction (site) where the beneficiary is receiving care, and compliance, as required, by appropriate regulatory and accrediting agencies. Our credentialing team will monitor provider offices during initial credentialing and thereafter during re-credentialing.

Health Insurance Portability and Accountability Act of 1996

TriWest requires all providers to follow the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA was enacted to:

  • Combat fraud, waste, and abuse
  • Improve portability of health insurance coverage
  • Simplify health care administration

HIPAA requires individual health care providers and institutional providers such as hospitals, their workforce members, and their contractors, to use and disclose Protected Health Information (PHI) only as permitted or required by the HIPAA privacy rule. PHI includes beneficiary-identifiable health details, such as individually identifiable health information.

Military Command Exception

A provider may use and disclose the PHI of individuals who are service members for activities deemed necessary by appropriate military command authorities to ensure the proper execution of the military mission. Exceptions pertaining to disclosures to command authorities of PHI involving service members seeking behavioral health services and substance abuse education services are outlined on the “Military Command Exception” page of the DHA Privacy and Civil Liberties Office website.

In the event of a disagreement between a commander and a DOD covered entity (including an affiliated health care provider) concerning disclosure of PHI, the DOD covered entity will, before making its determination, seek the advice of the cognizant legal advisor or command counsel, or the cognizant HIPAA privacy officer, or both, as appropriate. For more information in this area, please refer to Section 4 of Department of Defense Manual 6025.18.

TRICARE Provider Authorization and Certification

TRICARE only reimburses appropriately covered services for eligible beneficiaries provided by TRICARE-authorized providers. TRICARE-authorized providers must comply with all TRICARE requirements, TriWest published policy and procedures, and the TriWest TRICARE Provider Handbook applicable to credentialing.

Providers who are contracted to the network must also be certified and credentialed. All network providers must accept the assignment (i.e., participate). Non-network providers have the option to accept the assignment on a case-by-case basis. If a non-network provider accepts assignment, they are recognized as a participating non-network provider, committing to accepting the TRICARE-allowable charge as complete payment for covered services and filing claims for TRICARE beneficiaries. When a beneficiary files a claim for services rendered by a non-participating individual professional provider who is legally practicing and eligible for TRICARE authorization, the provider will be certified, and payment will be issued to the beneficiary.

Providers can access certification forms necessary for providers to become TRICARE-authorized online.

Non-participating providers do not have to accept the TRICARE-allowable charge or file claims for beneficiaries. By federal law, if a non-network provider does not participate on a particular claim, the provider may not charge more than 15% above the TRICARE-allowable charge (115%).

National Provider Identifiers (NPI). TRICARE providers should already have NPIs. If a provider does not have an NPI, they can complete the online NPPES application or download the National Provider Identifier Application/Update Form. Providers can find more information at CMS.gov.

TRICARE Credentialing

To join the TRICARE West Region network, a TRICARE-authorized provider, if not already credentialed with us, must complete the credentialing process and sign a contract with TriWest. Providers who are already credentialed must meet TRICARE certification requirements per TRICARE Operations Manual Chapter 4, Section 1, Paragraph 1.1. Please note that all network providers must accept Medicare on a claim-by-claim basis and must be Medicare participating providers. (Refer to TRICARE Policy Manual Chapter 11, Section 1.2 for more information).

The credentialing process requires verification of the provider’s education, board certification, license, professional background, malpractice history, and other pertinent data. A fully executed contract copy is forwarded by TriWest to the provider. Please note that credentialing approval is sent separately from the fully executed contract.

Providers must have a signed contract with TriWest and have received credentialing approval from TriWest to be considered a network provider. TriWest monitors each network provider’s quality of care and adherence to DOD, TRICARE, and TriWest policies. Network providers must be re-credentialed every three years.

Providers must meet VA-specific requirements as specified within the TRICARE Policy Manual, Chapter 11.

Individual Providers

To meet the minimum credentialing criteria established by TriWest, individuals must have:

  • Completed education and training required for the applicable specialty
  • A current, active and unrestricted license
    • Provider licenses must allow for independent practice, with the exception of Pastoral Counselors and Supervised Mental Health Counselors.
  • An unrestricted and active Drug Enforcement Agency (DEA) registration, as applicable to their license
  • An unrestricted and active controlled substance registration, as applicable to their license per their state requirements
  • Adequate malpractice or liability insurance per local requirements
  • Providers cannot participate if they:
  • Are barred from participating in federal programs
  • Have a felony conviction
  • Have a physical or mental condition that would unreasonably limit their ability to render high quality care
  • Have a substance dependency that is untreated or unmanaged
  • Have gaps in work history of more than six months

Provider types that can participate subject to credentialing requirements are specified in TRICARE Policy Manual, Chapter 11.

Institutional Providers

In order to participate, facilities must have:

  • An active and unrestricted license
  • Liability insurance that is active and adequate per state or locality requirements
  • Proper accreditation as applicable for the facility type
  • Facilities cannot participate if they are barred from participating in federal programs

For more information about becoming a network provider, visit TriWest’s Join Our Network page. Providers can check credentialing status online.

Charging Administrative Fees

Providers may not charge TRICARE beneficiaries administrative fees. Per the TRICARE Reimbursement Manual, Chapter 1, Section 19, providers may incur administrative expenses during the course of doing business. Most of these are normal expenses and payment for them is included in the payments made for the medical services rendered by the provider. Others are not covered because they are not medical services related to the treatment of an illness or injury. In either case, separate charges for administrative expenses are not allowed. Such expenses include:

  • Penalty or interest charges imposed on a beneficiary by a provider because of failure to make timely payment on a bill are not covered.
  • Provider administrative expenses such as charges for claims completion and furnishing medical records are not separately allowable.

Nondiscrimination Policy

All TRICARE-authorized providers agree not to discriminate against any TRICARE beneficiary on the basis of race, color, national origin, or any other basis recognized in applicable laws or regulations. To access the full TRICARE policy, refer to the TRICARE Operations Manual Chapter 1, Section 5.

Office and Appointment Access Standards

TRICARE access standards are designed to ensure that beneficiaries receive timely health care services conveniently located within a reasonable distance from their homes. Network providers must adhere to the following appointment access standards:

  • Preventive care appointment – Four weeks (28 days)
  • Routine care appointment – One week (7 days)
  • Specialty care appointment – Four weeks (28 days)
  • Urgent care – One day (24 hours)
  • Emergency care – Emergency services shall be available and accessible to handle emergencies within the service area 24 hours a day, seven days a week

Specialty Care Responsibilities

Pre-authorization for certain specialty care services is required. TRICARE Prime beneficiaries seeking specialty care require a referral from their PCM. PCMs and/or specialty care providers must coordinate with TriWest to obtain referrals and pre-authorizations. Please see the PCM section for more information.

TRM, Chapter 1, Section 28, Paragraph 2.0 states that in the case of a provider’s failure to obtain the required preauthorization, the provider’s payment shall be reduced by 10% of the allowable amount. Under the managed care contracts, a network provider’s payment can be subject to a greater than 10% reduction or a denial if the network provider has agreed to such a reduction or denial in the contract. These payment reduction penalties cannot be passed onto the beneficiary for payment. It is the provider’s responsibility to obtain pre-authorization when required.

Network behavioral health care providers can request authorizations for non-office based, outpatient (e.g., Partial Hospitalization Program, Intensive Outpatient Program and Opioid Treatment Program) mental health services without requesting a PCM referral first.

Specialty referral requirements vary by TRICARE beneficiary type and program option:

  • TRICARE Prime:
    • ADSMs: All civilian specialty care requires a referral from a beneficiary’s PCM and/or TriWest. In addition, pre-authorization from TriWest is required for certain services.
    • Active Duty Family Members (ADFM): Referrals to specialty care are required with the following exceptions:
      • Preventive care services from network providers
      • Urgent care services from network providers
      • Behavioral health care outpatient visits for medically necessary treatment for covered conditions
      • When using the POS option

Pre-authorization from TriWest is required for certain services.

  • TRICARE Select: Referrals are not required to TRICARE-authorized specialty care providers

Providers should submit referrals and pre-authorizations via the online referral management system on Availity.

Any specialty care outside of the indicated referral scope requires an authorization request or communication back to the beneficiary’s PCM for necessary referrals.

Opioid Safety Initiative (OSI)

The DHA and the VHA developed and implemented the Opioid Safety Initiative (OSI) to improve quality of life, reduce suffering from chronic pain, decrease opioid prescribing practices associated with complications, and promote safer opioid-related prescribing for ADSMs, Veterans and their families.

The OSI addresses the challenges of opioid dependency and closely monitors DOD and VA dispensing practices system-wide, including care that occurs in the community. It coordinates pain management through patient and provider education, enhanced testing and safety monitoring, thoughtful tapering plans, the use of complementary integrated health modalities (i.e., acupuncture, massage therapy, yoga, etc.) and cognitive behavioral therapy for pain.

The current OSI guidance provides prescribers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are being considered for or are currently on long-term opioid therapy. Recommended actions for providers to take include:

  • Perform a thorough assessment including all prior treatment approaches
  • Set realistic expectations for pain management early and review often
  • Request non-pharmacological/non-opioid treatment options when appropriate
  • Proceed with opioid treatment with caution, as briefly as possible with the lowest dose immediate release option (not PRN long acting formulations)
  • Reassess progress and safety at every visit. For example, drug screening or confirmation at least every six months, naloxone available, secure storage to protect others, consistently verify the state Prescription Drug Monitoring Program (PDMP) also known as Prescription Monitoring Programs – before prescribing any controlled substance each and every time a prescription is written, etc.
  • Stop and reassess if concerns begin to occur
  • Submit requests for substance abuse treatment when needed

Medical Documentation: Clear and Legible Reports (CLR)

Providers should return Clear and Legible Reports (CLR) for services rendered to ADSMs and MTF Prime beneficiaries. CLRs should be returned to the military hospital or clinic within 10 business days from the date of service for outpatient care. Inpatient discharge CLRs are due within 40 business days of discharge.

Outpatient CLRs should contain applicable information about the care provided such as:

  • Specialty evaluations
  • Lab and radiology reports
  • Preventive services
  • Clinical procedures
  • Ancillary care
  • Other clinical information obtained during the service

Inpatient CLRs should include:

  • Consultation reports
  • Operative reports
  • Discharge summaries

Providers must follow the CLR instructions included on the referral/authorization confirmation from TriWest. Providers may submit CLRs using HIE networks that are connected to the Government’s electronic health record system. If a provider does not have access to an HIE, they may submit CLRs online.

Updating Provider Information

Based on their TriWest contract, network providers are required to notify TriWest or their designated network subcontractor of any change in address, professional affiliation, tax identification number (TIN), or licensure status. TriWest often partners with a network subcontractor (e.g., Blue Cross Blue Shield plans) to develop and manage the provider network. Our provider contracts specify the designated network subcontractors that manage provider data, credentialing, and other functions as designated by TriWest. Some provider contracts may not have a designated network subcontractor. In such cases, providers should provide the updated information directly to TriWest.

Providers should make their best efforts to notify TriWest or their designated network subcontractor at least 60 days before the change date, or at the earliest opportunity if such prior notice is impracticable. If advance notification is not possible, providers should notify TriWest or their network subcontractor no later than 10 business days after the effective change date.

Prompt notification to TriWest or their designated network subcontractor of changes in information allows beneficiaries seeking health care services and providers seeking to refer care to access the most accurate provider information. Additionally, it allows TriWest to send payments to the correct address and avoids PHI disclosures.

The Network Provider Directory, located at https://tricare.triwest.com/en/beneficiary/, helps beneficiaries and other providers locate TRICARE network providers. To confirm the accuracy of individual listings and information, network providers must visit the online Network Provider Directory at https://tricare.triwest.com/en/beneficiary/. To update demographic information, use Availity or submit a TRICARE Provider Roster at www.triwest.com.

If you are a network provider and do not see your practice listed in the Network Provider Directory, email TriWest providerservices@triwest.com or call the TriWest Customer Service line 1-866-690-0885 to inquire about being listed. Providers interested in joining the TriWest network should go to JoinOurNetwork.TriWest.com.

Non-network providers are not included in the Network Provider Directory. Doctors, hospitals, and other health care professionals who are TRICARE authorized and have submitted a claim over the past 14 months can be found on the online Non-Network Provider Directory. To update and verify demographic information, please visit https://tricare.triwest.com/en/provider/.

Provider Contract Provisions

The following provisions are applicable to services rendered pursuant to the TRICARE/CHAMPUS program requirements as administered by TriWest and will be incorporated by reference into the Provider’s contract as fully set forth therein. The Spanish version of the Provider Handbook is provided for convenience only; the English version of all contractual documents between TriWest and the provider, including but not limited to the TRICARE Provider Handbook, shall be exclusively used for legal interpretation. For avoidance of doubt, in the event of any ambiguity or disagreement between the terms of the Spanish version of the Provider Handbook and the original English version, the English version shall take precedence and control.

Definitions

Term

Definition

Adequate Medical Documentation, Medical Treatment Records

Adequate medical documentation contains sufficient information to justify the diagnosis, the treatment plan, and the services and supplies furnished. Under TRICARE/CHAMPUS, it is required that adequate and sufficient clinical records be kept by health care provider(s) to substantiate that specific care was actually and appropriately furnished, was medically necessary and appropriate, and to identify the individual(s) who provided the care. All procedures billed must be documented in the records. In determining whether medical records are adequate, the records will be reviewed under the generally acceptable standards such as the applicable Joint Commission (formally Accreditation of Healthcare Organizations) standards, the Peer Review Organization (PRO) standards, (and the provider’s state or local licensing requirements) and other requirements specified by TRICARE Requirements. In general, the documentation requirements for a professional provider are not less in the outpatient setting than the inpatient setting.

Authorized Provider

A hospital or institutional provider, physician, or other individual professional provider, or other provider of services or supplies specifically authorized to provide benefits under CHAMPUS pursuant to TRICARE Requirements. Provider shall be an Authorized Provider.

Balance Billing

A provider seeking any payment, other than any payment relating to applicable deductible and cost sharing amounts, from a beneficiary for TRICARE/CHAMPUS covered services for any amount in excess of the applicable TRICARE/CHAMPUS allowable cost or charge. Balance billing is prohibited.

Beneficiary Liability

The legal obligation of a beneficiary, his or her estate, or responsible family member to pay for the costs of medical care or treatment received. Specifically, for the purposes of services and supplies covered by TRICARE, beneficiary liability includes any annual deductible amount or cost-sharing amounts. Beneficiary liability also includes any expenses for medical or related services and supplies not covered by TRICARE.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

A term also used for TRICARE and as referenced by the relevant authorities, including TRICARE Requirements. TRICARE and CHAMPUS shall be considered synonymous and interchangeable terms for the purpose of this TRICARE Provider Handbook.

CHAMPUS Maximum Allowable Charge (CMAC)

CMAC is a nationally determined allowable charge level that is adjusted by locality indices and generally, but not always, is equal to or greater than the Medicare Fee Schedule amount.

Defense Health Agency (DHA)

A joint, integrated combat support agency that enables the Army, Navy, Air Force, Marine Corps, Coast Guard, Space Force, and Coast Guard medical services to provide a medically ready force and ready medical force to combatant commands in both peacetime and wartime. DHA is considered part of the government.

Director

The Director of the Defense Health Agency, Director, TRICARE Management Activity, or Director, Office of CHAMPUS. Any references to the Director, Office of CHAMPUS, or OCHAMPUS, or TRICARE Management Activity, shall mean the Director, Defense Health Agency (DHA). Any reference to Director shall also include any person designated by the Director to carry out a particular authority. In addition, any authority of the Director may be exercised by the Assistant Secretary of Defense (Health Affairs).

Department of Defense (DOD)

The DOD is responsible for providing the military forces of the United States of America needed to deter war and protect the security of the country. DOD is also considered part of the government.

Medically (or Psychologically) Necessary Preauthorization (or prior)

A pre (or prior) authorization for payment for medical/surgical or psychological services based upon criteria that are generally accepted by qualified professionals to be reasonable for diagnosis and treatment of an illness, injury, pregnancy, and mental disorder. The term prior authorization is commonly substituted for preauthorization and has the same meaning. Provider reimbursement may be reduced or claims denied if services were provided without appropriate Preauthorization.

Military Health System (MHS)

The system that is operated by the DOD and is responsible for providing health services through both MTFs and private sector care to TRICARE eligible beneficiaries, composed of uniformed service members, military retirees, and family members. MHS is also considered part of the government.

Military Treatment Facility (MTF)

A military facility that operates within the MHS provide and directs care of TRICARE Beneficiaries. MTFs are also considered part of the government.

Network Subcontractor

The health plans with whom TriWest contracts to include providers in the TriWest provider network.

Preauthorization (or prior)

A decision issued in writing, or electronically by the Director, TRICARE Management Activity, TriWest, or a designee, that TRICARE benefits are payable for certain services that a beneficiary has not yet received. The term prior authorization is commonly substituted for preauthorization and has the same meaning. Provider reimbursement may be reduced or claims denied if services were provided without appropriate preauthorization. Preauthorization is not a guarantee of payment of a claim.

TRICARE Beneficiary/Beneficiaries/MHS Eligible Beneficiary

An individual who has been determined to be eligible for TRICARE/CHAMPUS benefits as set forth in TRICARE Requirements. TRICARE Beneficiary programs include TRICARE Prime and TRICARE Select.

TRICARE/TRICARE Program

A component of the MHS. The TRICARE Program is the means by which managed care activities designed to improve the delivery and financing of health care services in MHS are carried out.

TRICARE Covered Services

Services, items and supplies for which benefits are available to TRICARE Beneficiaries in accordance with the rules, regulations, policies and instructions of DHA and DOD.

TRICARE Requirements

Title 10, United States Code, Chapter 55; 32 CFR Part 199; TRICARE Policy Manual (TPM); TRICARE Reimbursement Manual (TRM); TRICARE Operations Manual (TOM); and TriWest TRICARE Provider Handbook and TriWest Policies and Procedures. As of the effective date of these TRICARE Terms and Conditions, TRICARE Manuals may be found at: https://manuals.health.mil/.

Exclusions and Terminations

TriWest and Network Subcontractors have the right to immediately terminate Provider Agreements upon written notice to the provider for any of the events listed below:

  • Provider’s state or federal license or authorization to do business is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily), placed on probation, or provider’s other applicable license or accreditation is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily).
  • Provider’s professional liability coverage as required under Provider’s Agreement is reduced below required amounts or is no longer in effect.
  • Provider fails to meet TriWest’s or Network Subcontractor’s credentialing, re-credentialing, quality management or utilization management criteria, or fails to comply with quality management or utilization management processes.
  • Provider fails to provide material information or provides erroneous information on Provider’s credentialing application or re-credentialing application.
  • Provider is no longer Medicare-eligible, Medicaid-eligible, or is not eligible to participate in another government program.
  • Provider or any of its officers is arrested or indicted on felony charges that directly or indirectly relate to provisions of services under the Provider’s Agreement, and TriWest and Network Subcontractors make a reasonable and good faith determination that the nature of the charges is such that termination is needed to avoid unnecessary risk or harm to beneficiaries that could occur during the pendency of the criminal proceedings.
  • The Director, DHA, or designee may exclude any provider based on 32 CFR § 199.9 provisions (fraud, abuse and conflict of interest). The exclusion period is at the discretion of DHA. DHA Program Integrity will send written notice to the Provider of the proposed exclusion, and the potential effect thereof. Provider may submit evidence and written argument regarding the proposed exclusion. DHA Program Integrity has sole authority to issue an Initial Determination of Exclusion. Written notice of this decision will include the basis for the exclusion, the exclusion length, and the effect of the exclusion. The determination also outlines the earliest date on which DHA Program Integrity will consider a request for reinstatement, the requirements for reinstatement, and appeal rights available. Exclusion of a Provider will be effective 15 calendar days from the date of the initial determination. The Director, DHA or designee has sole authority for approval of any request for reinstatement. Within 15 business days of DHA Program Integrity notifying TriWest of an exclusion action, TriWest will provide written notice, sent by certified mail, return receipt requested, that the Provider’s agreement has been cancelled.
  • TriWest will initiate termination action based on a finding that Provider fails to meet the qualifications to be an authorized TRICARE/CHAMPUS provider. The termination period will be indefinite and will end only after Provider has successfully met the established qualifications for authorized status under TRICARE and has been reinstated as outlined in TOM Ch. 13 Section 5 Subsection 10.0.
  • TriWest will initiate termination action based on a finding that the provider fails to meet the qualifications to be an authorized TRICARE/CHAMPUS provider. The termination period will be indefinite and will end only after Provider has successfully met the established qualifications for authorized status under TRICARE and has been reinstated as outlined in TOM Ch. 13 Section 5 Subsection 10.0.
  • TriWest and Network Subcontractor, in their sole discretion, have the right to immediately terminate or pursue other administrative action upon TriWest learning that Provider had not been credentialed in compliance with the TriWest Credentialing Committee Policy & Procedure.

Notification

All notices and other communications to a Party must be in writing, hand delivered, delivered by prepaid commercial courier services with tracking capabilities, faxed, or delivered by the U.S. mail to the address listed on the signature page of the Provider’s Agreement. The Parties may change the address of record by notifying the other Party of the new address. Notice shall be complete upon the earlier of actual receipt or five (5) days after being deposited into the U.S. mail. Notices and other communications in writing need not be mailed either by registered or certified mail, although a signed return receipt received through the U.S. Post Office shall be conclusive proof between the Parties of delivery of any notice or communication and of the date of such delivery.

Provider shall notify TriWest or Network Subcontractor in writing immediately upon learning of any action, policies, determinations or internal or external developments that may have a direct impact on Provider’s ability to perform its obligations under the Provider’s Agreement. Such matters shall include, but are not limited to:

  • Any change in ownership, specialty services provided, Medicare designation (including but not limited to sole community, critical access, etc.), or location of facilities
  • Action against or lapse of Provider’s license, certification, accreditation, or certificate of authority
  • Loss of hospital privileges
  • Arrest or indictment
  • Reduction in insurance coverage below the required limits set forth for the applicable Program, or termination of insurance coverage
  • Any activity that compromises the confidentiality and security of the beneficiaries’ medical records
  • Exclusion or any other penalty from Medicare, Medicaid, or any other federal health care program
  • Provider shall complete TRICARE required training that will be determined at a later date and reflected in the next version of the TriWest TRICARE Provider Handbook.

Provider Directory

TriWest may periodically include the provider’s name, gender, work address, work fax number, work telephone number, whether the provider is accepting new patients, specialty and sub-specialty, and willingness to accept beneficiaries in a network provider directory. The provider is responsible for notifying TriWest or network subcontractor of any changes of address, phone or fax number, or specialty services rendered within 10 business days.

Compliance

Providers must comply with all applicable state and federal laws as well as regulations and all rules, policies and procedures of the applicable program including without limitation to credentialing, peer review, referrals, utilization review/management, clinical practice guidelines, case management and quality assurance programs and procedures established by TriWest or the applicable health care program including submission of information concerning provider and compliance with Preauthorization requirements, care approvals, pharmacy, dental and DME utilization requirements, care approvals, concurrent reviews, retrospective reviews, discharge planning for inpatient admissions, critical event notifications, quality of care audits, return of medical records, and preauthorization of referrals.

Ancillary Providers

If laboratory tests billed by a non-network provider were performed outside the non-network provider’s office, the place where the laboratory tests were performed must be provided for TriWest to approve arrangements for laboratory work submitted by network providers.

To be covered, the services must have been ordered by a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) and the laboratory must meet the requirements to provide the services as required under the 32 CFR § 199 and DHA instructions.

For TRICARE Prime beneficiaries, ancillary services must be ordered by the PCM.

Credentialing and Certification Requirements

Providers cannot have had any state license terminated for cause, have relinquished any state license after being notified in writing by that state of potential termination for cause, or have relinquished any state license for any reason that would violate TRICARE requirements (as defined in the Provider TRICARE Terms and Conditions) whether or not provider had been notified by that state of potential termination for cause.

Providers who have not submitted a claim or whose services have not been submitted on a claim within the past two years may be moved from the active file to the inactive file. However, even if the provider remains on the active file, if a claim is received from a provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years, the provider must be fully recertified. Providers who have been terminated or suspended shall not be deleted. Suspended, terminated, or excluded providers shall remain on the file as flagged providers indefinitely or until the flag is dropped because the suspended provider has been reinstated.

Professional Liability Coverage

Providers must provide and maintain professional liability insurance in an amount in accordance with the laws of the state in which the care is provided and TRICARE Requirements, including TriWest TRICARE Terms and Conditions.