TRICARE July 2026 Provider Pulse

New TRICARE Clinical Care Phone Numbers

On Aug. 4, 2026, the TriWest Healthcare Alliance (TriWest) clinical care phone numbers will be changing. There will be outreach to TRICARE beneficiaries who currently interact with the Clinical Operations staff to ensure a smooth transition. In addition, the old numbers will be transferred to the new numbers for 30 days following this change.

Please note: The TRICARE West Region’s main phone line remains the same at 888-TRIWEST (874-9378).

If you have TRICARE patients currently enrolled in a clinical care program or who regularly interact with TriWest Clinical Operations staff, feel free to mention this change and alert them to watch for communications with their point of contact’s new number.

Update to TRICARE ACD Education Requirements

To remain compliant with Chapter 18, Section 3, of the TRICARE Operations Manual (TOM) requirements, all Autism Care Demonstration (ACD) providers shall complete the ACD Provider Education annually and retain evidence of attendance/completion of the latest published version. If the ABA provider fails to complete the ACD Provider Education by the final day of the calendar year, a 10% claims penalty for all ABA-rendered services during the non-compliant period will be imposed.

The ACD Provider Education course is offered as an on-demand, web-based module that can be accessed at any time for your convenience. To access the training:

• Log in to Availity.com.
• Go to the TRICARE West Region Payer Space.
• Click on the Access TriWest Leaning Center tile.
• Search “Annual Provider Training.”
• You can either enroll for a later training date or begin the training by clicking “Start Now.”

TRICARE Qualified Behavior Analyst and Applied Behavior Analysis Requirements

Effective immediately, the Qualified Behavior Analyst (QBA) credential alone does not qualify a provider as a TRICARE Applied Behavior Analysis (ABA) Supervisor. You cannot bill CPT code 97155 using only the QBA certification.

Exceptions & Criteria

• Dual Credentialing: A QBA qualifies as an ABA Supervisor only if they hold an active, concurrent state license.
• Licensed Behavior Analysts: QBAs who are also Licensed Behavior Analysts meet the TRICARE Operations Manual (TOM) criteria.
• Solo Credentials: Providers holding only the QBA credential cannot render or bill for 97155 services.

Required Actions

1. Review Staff Credentials: Audit your current clinical supervisor rosters immediately.
2. Verify State Licenses: Ensure all rendering providers for 97155 possess the required state licensure/certification.
   1. Please reference TOM Ch. 18 Section 3: 8.4.1: Authorized ABA Supervisors (BCBA, BCBA-D, or Clinical Psychologist).
3. Update Billing Practices: Cease claims submission for 97155 if the rendering supervisor only holds a QBA certification.

Failure to comply with this policy will result in immediate claim denials and potential recoupment.

Avoid TRICARE Referral Delays: 3 Things to Check

To help ensure timely processing of referral requests, please keep the following in mind when submitting care requests:

• Use the Originally Approved Diagnosis – When submitting a request for subsequent or additional care, list the originally approved diagnosis as the primary diagnosis. Additional diagnoses may be included, but only as secondary.
• Match the Authorized Referral to the Requesting Provider – The provider submitting the Requests for Service (RFS) must be the same provider to whom the referral was authorized.
• For example, if a Primary Care Manager (PCM) referral is authorized to a general surgeon and that surgeon determines surgery is needed, the surgery request must be submitted by the surgeon, not the ambulatory surgery center.
• Ensure an Approved PCM Referral is in Place – When requesting additional care, confirm the requesting provider has an approved PCM referral, and that the request reflects the same approved diagnosis and specialty to which care was originally authorized.

Following these steps helps avoid processing delays and keeps care moving forward for beneficiaries.

Understanding TRICARE Intensive Outpatient Program Guidelines

In healthcare, IOP stands for Intensive Outpatient Program, a distinct level of care positioned between standard outpatient mental health services and partial hospitalization programs (PHP).

Unlike routine outpatient care (typically 30–60-minute individual sessions with a therapist or psychiatrist, scheduled weekly to every few months), IOPs combine group and individual treatment into longer, structured blocks attended 3-5 days per week. They serve patients who require a higher level of support than weekly therapy can offer yet retain enough stability to maintain their daily obligations.

The Center for Medicare Services (CMS) began covering IOPs in 2024 and requires that they meet the following criteria for reimbursement:

• Operate as distinct and organized programs
• Serve patients with acute mental illness
• Provide at least 9 hours of services per week
• Include physician oversight and certification of need
• Include a structured schedule of multidisciplinary services and an individualized plan of care

For more information visit the TRICARE Provider Resources Page, Medicare’s Final Rule on IOP Coverage, and the billing requirements for Intensive Outpatient Services with New Condition Code 92.

TRICARE Policy Manual Outlines New TENS Device Guidelines

According to updates to Chapter 8 (section 20.2) of the TRICARE Policy Manual, Transcutaneous Electrical Nerve Stimulation (TENS) devices will only be covered for treatment of post-operative pain. They are excluded from coverage for any other purpose. This coverage is limited to an initial period of 30 days from the day of the surgery. Additionally, it can only be extended to a maximum of 90 days, with required monthly documentation of necessity by an authorized provider.

What is covered

• TENS devices and associated supplies
• Use for acute post‑operative pain only
• An initial 30‑day coverage period, with the option to extend up to a maximum of 90 days if medically justified

What is not covered

• TENS devices for any other condition or type of pain
• Use for chronic pain, including low back pain

What’s new in this update

• A defined coverage window (30 days, extendable to 90)
• Clarification that post‑operative pain is the only covered use
• Exclusion of all other indications beyond the post‑operative setting

Updates to the TENS device policy went into effect July 13, 2026, under TRICARE Policy Manual Change 53.

TRICARE Provider Handbook Updates

The following information will be added to the TRICARE Claims Reconsiderations section of the TRICARE Provider Handbook:

Reconsiderations

Providers can submit a claim review request for reconsideration when they need to dispute the outcome of a processed claim.

Examples of issues that may need secondary review include:

• Allowed amount disputes
• OHI issues
• Timely filing denials
• Penalties for no authorization
• Denial code(s)

Download the Provider Claims Reconsideration form and mail or fax to the address below. Please include all supporting documentation relevant to the review request. A claim reconsideration must be submitted no later than 90 days from the date of the remittance.

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450
Fax: 866-852-1969

Please note: Claims denied for lack of medical documentation are handled by PGBA. Complete the Medical Record Request Cover Sheet and send or fax it along with the records to the following address or fax number.

TRICARE West – Med Records
P.O. Box 202165
Florence, SC 29502
Fax: 877-989-0047