TRICARE April 2026 Provider Pulse

TriWest Seeks Participants for Clinical Committees

TriWest is seeking TRICARE providers to participate in its clinical committees for peer review and credentialing.

TriWest holds virtual committee meetings monthly and sends materials to participants in advance via encrypted email. Providers call in to the meeting to participate (some meetings include screen sharing). There is no travel required and providers are compensated for the hours they dedicate to this valuable work.

We are actively seeking participants on each of the following committees:

• Peer Review Committee: Responsible for oversight of the TriWest peer review process. Peer reviews are completed outside this committee by similar specialists, and the confirmed clinical quality concerns are discussed monthly. Cases include medical, surgical, behavioral, and integrated health. TriWest seeks providers who are in active practice to review the peer review information and discuss appropriate improvement plans for quality of care with the committee. The completed peer reviews are provided prior to the meetings and may take several hours to review per month. Committee meetings are approximately two hours long.
• Credentialing Committee: TriWest seeks providers who are in active practice to evaluate and make decisions regarding qualifications for the VA provider network in accordance with TriWest policy and URAC accreditation standards, including review of subcontracted provider networks. Members are provided with the application packets of providers who have had actions on their licensure, malpractice or legal issues to review in advance of the meeting, which may require several hours to complete. Committee meetings are approximately two hours long.

It’s important that network providers have a say about the network they participate in. If you’re interested in serving as a committee member, please contact Eric A. Heuck, Vice President, Procurement, at eheuck@triwest.com.

Know Who to Contact: TriWest and the MTF in the Beneficiary Journey

TriWest and Military Treatment Facilities (MTF) each support different parts of the TRICARE beneficiary journey. Understanding who to contact, and when, helps ensure your questions are answered quickly and accurately, reduces delays, prevents misrouting, and supports smoother care coordination for beneficiaries.

Using the correct point of contact also helps streamline communication and keeps care moving forward without unnecessary delays.

For more information on who to contact visit the When to Contact the MTF or TriWest Quick Reference Guide.

Update to TRICARE Referral and Authorization Process

Beginning April 30, 2026, The TRICARE West Region’s Alternative Referral and Authorization form will no longer be available for use.

Please use the online referral management system available via the provider portal, Availity. This is the fastest way to ensure care for your patients.

Once logged in, go to your TRIWEST – TRICARE Payer Space. Under Applications, select the tile titled “Submit Referral/Auth.” Clicking this will launch the online referral management system.

For more information on using the online referral management system, please review the Referral and Authorizations User Guide.

You can still submit your referrals and authorizations requests via fax to 866-852-1893. For newborn and NICU patients, please fax the face sheet to 866-852-1885.

If you have issues submitting your referral and authorization through the online referral management tool, please contact TriWest via the chat feature in Availity or at 888-TRIWEST (874-9378). We’re here to help Monday – Friday from 8 a.m. to 6 p.m. in your time zone.

TRICARE Policy Manual Update: Prophylactic Mastectomy, Prophylactic Oophorectomy, and Prophylactic Hysterectomy

Effective March 17, 2026, TRICARE Policy Manual Section 5.3, Prophylactic Mastectomy, Prophylactic Oophorectomy, and Prophylactic Hysterectomy, was updated under Change 48 (Revision C-46). The manual changes expand coverage criteria for risk-reducing surgeries, align policy with current National Comprehensive Cancer Network (NCCN) and American College of Obstetricians and Gynecologists (ACOG) guidelines, and introduce new covered procedures and terminology.

All TRICARE West Region network providers need to review these changes and update their clinical and administrative workflows accordingly.

New CPT Codes (Section 1.0)

The following CPT code ranges have been added to the list of covered procedures under Section 5.3:

• 58570 – 58573 — Laparoscopic hysterectomy procedures
• 58700 – 58720 — Salpingectomy procedures

Providers need to ensure these new codes are used when applicable on authorization requests and claims submissions.

Updated Description and Terminology (Section 2.0)

This section has been revised with several important changes to language and scope, including the following:

New "risk-reducing surgeries" terminology — The policy now formally recognizes the term "risk-reducing surgeries" as an alternative name for prophylactic mastectomy, prophylactic oophorectomy, and prophylactic hysterectomy. The following sentence has been added: "These surgeries are also called risk-reducing surgeries."

Expanded definition of high-risk individuals — The definition of someone who qualifies as a high-risk individual has been broadened as follows:

• A high-risk individual is one with a family history or personal history of cancer in the breast, ovaries, or uterus; or as otherwise defined by the NCCN or ACOG, including individuals with a hereditary cancer syndrome.

Key additions include:

• Uterus is now listed alongside breast and ovaries as a qualifying cancer site for personal history.
• "Or personal history" is now explicitly separated from family history for clarity.
• Individuals with hereditary cancer syndrome (as defined by NCCN or ACOG) are now expressly included in the high-risk definition.

NCCN guideline precedence established — The prior language “Carefully selected indications have been developed for prophylactic mastectomy and are included in this policy” was removed and replaced with the following language: "For this section, where NCCN and ACOG guidelines differ, NCCN guidelines should take precedence." This is a significant clarification for providers managing cases where NCCN and ACOG recommendations diverge.

Prophylactic Bilateral Mastectomy (Section 3.1)

Terminology change — The phrase "Bilateral prophylactic mastectomies" was changed to "Prophylactic bilateral mastectomies" to standardize clinical terminology.

Section 3.1.2 — The parenthetical reference to Hereditary Breast and Ovarian Cancer Syndrome was revised as the informal "Family" prefix was removed to align with NCCN naming conventions.

Sections 3.1.3 through 3.1.5 — These sections, effective since September 1, 2017, are now emphasized in the updated policy. They cover the following conditions:

• 3.1.3: One or more pathogenic genetic mutations when indicated by NCCN or ACOG: ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53
• 3.1.4: Chest wall radiation before 30 years of age
• 3.1.5: Any other clinical factor for which NCCN or ACOG recommend consideration of a prophylactic bilateral mastectomy

Providers need to verify authorization requests reference the correct genetic mutation list and cite the applicable subsection.

Section 3.1.6 — The phrase "the patient presents with either any of the above (or both) clinical presentations" was simplified to "the patient presents with any of the above clinical presentations."

Prophylactic Contralateral Mastectomy (Section 3.2)

Terminology change — The phrase "Unilateral prophylactic mastectomies" was changed to "Prophylactic contralateral mastectomies." This accurately describes the procedure as a risk-reducing mastectomy of the contralateral (opposite) breast after a cancer diagnosis in one breast.

Section 3.2.5 — The "Family" prefix was removed from "Hereditary Breast and Ovarian Cancer Syndrome."

Section 3.2.6 — Effective September 1, 2017, coverage now explicitly includes patients with one or more of the following pathogenic genetic mutations, when indicated by NCCN or ACOG recommendations: ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53. This mirrors Section 3.1.3 and extends the same genetic mutation coverage criteria to the contralateral mastectomy indication.

Section 3.2.7 — Effective September 1, 2017, coverage is now included for any other clinical factor for which NCCN or ACOG recommend the consideration of a prophylactic contralateral mastectomy. This ensures parity between bilateral and contralateral mastectomy coverage criteria.

Prophylactic Oophorectomy and Salpingectomy (Section 3.3)

Major expansion of covered procedures — This section was substantially revised. The previous language of "Prophylactic salpingo-oophorectomy is covered" was expanded to the following: "Prophylactic salpingo-oophorectomy or oophorectomy (or salpingectomy, when indicated by ACOG or NCCN recommendations) are covered."

This is a significant change. Coverage now explicitly includes the following conditions:

• Salpingo-oophorectomy
• Standalone oophorectomy (newly added as a separate option)
• Salpingectomy when indicated by ACOG or NCCN recommendations (newly added)

Section 3.3.7 — New: Pathogenic genetic mutations — Effective September 1, 2017, coverage now includes patients with one or more of the following pathogenic genetic mutations, when indicated by NCCN or ACOG recommendations:

• BRCA1, BRCA2
• BRIP1
• Lynch Syndrome genes: MSH2, MLH1, MSH6, PMS2, EPCAM
• RAD51C, RAD51D
• PTEN

Note: This genetic mutation list differs from the mastectomy list in Sections 3.1.3 and 3.2.6. It includes Lynch Syndrome genes, BRIP1, RAD51C, and RAD51D, which are specific to ovarian cancer risk, while excluding ATM, CDH1, CHEK2, STK11, and TP53.

Section 3.3.8 — New: NCCN/ACOG clinical factor coverage — Effective September 1, 2017, coverage is now included for any other clinical factor for which NCCN or ACOG recommend the consideration of a prophylactic salpingo-oophorectomy, salpingectomy, or oophorectomy. This is the broadest catch-all provision in the section, ensuring that emerging evidence-based recommendations are covered.

Prophylactic Hysterectomy (Section 3.4)

Section 3.4.2 — Lynch Syndrome terminology — The previous language referenced only Hereditary Non-Polyposis Colorectal Cancer (HNPCC). The updated language now reads as follows: "For women who have been diagnosed with Hereditary Non-Polyposis Colorectal Cancer (HNPCC) or Lynch Syndrome or are found to be carriers of HNPCC or Lynch Syndrome-associated mutations." Lynch Syndrome was added as a diagnostic equivalent to HNPCC and as a mutation carrier status. This reflects current medical terminology where Lynch Syndrome largely replaced the HNPCC designation.

Section 3.4.3 — New: Opportunistic concurrent procedures — This is an entirely new provision: "Opportunistic salpingo-oophorectomies, salpingectomies, and oophorectomies concurrent with a prophylactic hysterectomy may be covered when indicated by ACOG or NCCN guidelines."

This permits coverage for a risk-reducing oophorectomy and/or salpingectomy performed simultaneously as a prophylactic hysterectomy when clinical guidelines support the concurrent approach. This aligns with ACOG's practice of recommending opportunistic salpingectomy at the time of hysterectomy for ovarian cancer risk reduction.

Summary of All Changes

Section	Change Type	What Changed
1.0	Addition	CPT codes 58570–58573 (laparoscopic hysterectomy) and 58700–58720 (salpingectomy) were added.
2.0	Expansion	"Risk-reducing surgeries" terminology was added; uterus was added to high-risk cancer sites; hereditary cancer syndrome was included in high-risk definition; NCCN precedence over ACOG was established.
3.1	Revision	Terminology was standardized to "Prophylactic bilateral"; "Family" was removed from hereditary syndrome name; dense breast criteria language was simplified.
3.1.3 – 3.1.5	Emphasis	Genetic mutation, chest wall radiation, and NCCN/ACOG clinical factor criteria were highlighted (effective since 9/1/2017).
3.2	Revision + Addition	Terminology was changed to "Prophylactic contralateral"; "Family" was removed from hereditary syndrome name; new Sections 3.2.6 (genetic mutations) and 3.2.7 (NCCN/ACOG factors) were added.
3.3	Major Expansion	Standalone oophorectomy and salpingectomy were added as separately covered procedures; new Sections 3.3.7 (genetic mutations including Lynch Syndrome genes, BRIP1, RAD51C, RAD51D) and 3.3.8 (NCCN/ACOG factors) were added.
3.4	Expansion	Lynch Syndrome was added alongside HNPCC in Section 3.4.2; new Section 3.4.3 was added for opportunistic concurrent procedures with prophylactic hysterectomy.

With this policy change, TRICARE West Region providers should take the following action:

1. Review the updated Section 5.3 policy language. Familiarize yourself and your clinical and administrative staff with the revised criteria, especially with the expanded genetic mutation lists, the new salpingectomy coverage, and the NCCN precedence directive.
2. Update prior authorization submissions. Ensure authorization requests for prophylactic surgeries reference the correct and current policy criteria. Use the newly added CPT codes 58570–58573 and 58700–58720 where applicable.
3. Verify genetic testing documentation. When submitting authorizations based on pathogenic genetic mutations, confirm the specific mutation is on the applicable list:
   1. Mastectomy (3.1.3 / 3.2.6): ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53
   2. Oophorectomy/Salpingectomy (3.3.7): BRCA1, BRCA2, BRIP1, Lynch Syndrome (MSH2, MLH1, MSH6, PMS2, EPCAM), RAD51C, RAD51D, PTEN
4. Apply NCCN guideline precedence. When NCCN and ACOG guidelines differ regarding prophylactic surgical indications under this section, NCCN guidelines now take precedence.
5. Document hereditary cancer syndromes. The expanded high-risk definition now explicitly includes individuals with a hereditary cancer syndrome as defined by NCCN or ACOG. Ensure this is documented in the clinical record to support authorization.
6. Consider opportunistic concurrent procedures. New Section 3.4.3 permits coverage for salpingo-oophorectomies, salpingectomies, and oophorectomies performed concurrently with a prophylactic hysterectomy when indicated by ACOG or NCCN guidelines. Document the clinical indication accordingly.

Reference Information

• Policy: TRICARE Policy Manual 6010.63-M, Chapter 4, Section 5.3
• Revision: C-46, March 10, 2026 (Change 48)a
• Effective Date: March 17, 2026
• Authority: 32 CFR 199.4(c)(2)
• Full Policy Text: manuals.health.mil
• TRICARE West Region Provider Portal: tricare.triwest.com
• Customer Service: 888-TRIWEST (874-9378)

TRICARE Policy Manual Update: HPV Testing Expansion

This communication reflects the substantive changes introduced in TRICARE Policy Manual Change 48. The most significant update is the expansion of primary HPV testing as a standalone screening option, removing the previous requirement that HPV DNA testing be performed only in conjunction with a pap smear.

TRICARE has updated its cervical cancer screening policy to align with current clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP). The following summarizes key changes affecting covered screening services.

Key Policy Changes

1. Primary HPV Testing Now Covered as a Standalone Screening Option
   Previous Policy: HPV DNA testing was covered as a cervical cancer screening only when performed in conjunction with a Pap smear (co-testing), and only for women age 30 and older.
   New Policy: Primary HPV DNA testing is now covered as a standalone cervical cancer screening option under the following conditions:
   • Every five years for women ages 30 through 65
   • FDA-cleared HPV self-collection testing methods are covered
   
   
   HPV DNA testing is no longer required to be billed in conjunction with a Pap smear to qualify for reimbursement as a preventive screening.
2. HPV Self-Collection Testing Now Covered
   New Coverage: FDA-cleared HPV self-collection testing methods are now explicitly covered for cervical cancer screening, subject to the same age (30–65) and frequency (every 5 years) parameters as clinician-collected HPV testing.
3. Pelvic Examination Language Updated

Previous Policy: A pelvic examination "should" be performed as part of a well woman exam in conjunction with Pap testing.

New Policy: A pelvic examination "may" be performed as part of a well woman exam. This change reflects updated guidance that pelvic examinations are not mandatory for cervical cancer screening and should be based on clinical judgment and patient preference.

The following screening parameters remain unchanged:

Screening Method	Age Range	Frequency
Pap test (cervical cytology) alone	21–65	Every 3 years
Primary HPV testing	30–65	Every 5 years
Co-testing (Pap + HPV)	30–65	Every 5 years

Billing Implications

• Primary HPV screening (CPT 87624): May now be billed independently without an accompanying Pap test for women ages 30–65
• HPV self-collection: Use CPT 87624 for laboratory analysis; document FDA-cleared self-collection method in medical record
• Co-testing: Continue to bill cervical cytology code (88141–88175 series) plus HPV code (87624) together
• Pap test alone: No change to billing for ages 21–65

TRICARE Provider Handbook Updates

1. A bullet point will be added under the Provider Information – Provider Contract Provisions – Exclusions and Terminations section of the TRICARE Provider Handbook:

• Provider Information – Provider Contract Provisions – Exclusions and Terminations
  • Provider or any of its officers is arrested, indicted, charged with, or convicted of 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.
  • Under Terminations: Provider fails to comply with Director, DHA or designee reimbursement and claims policy directives.

2. A bullet point will be added under the Provider Information – Provider Contract Provisions – Compliance section:

• Providers must comply with all applicable state and federal laws as well as regulations and all rules, directives, 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.
• Provider shall promptly respond to TriWest inquiries concerning TRICARE Beneficiary complaints and grievances. Provider’s failure to cooperate with TriWest’s efforts to resolve TRICARE Beneficiary complaints (e.g. not timely responding to TriWest’s letters and/or phone calls regarding TRICARE Beneficiary complaints) is a failure to comply with the terms and conditions of this Provider Handbook, which is a material breach of Provider’s Agreement.

3. A “Disputes Impacting Network Status” section will be added. It will outline the process if the TriWest Credentialing Committee denies or restricts a provider’s network participation status.