TRICARE network providers are required to follow these appointment access standards for beneficiary care.
Providers can submit a grievance by mail or fax. Learn more on our Grievances page.
Appeals can be submitted online, by mail or fax. Learn more about what types of claims and authorizations can be appealed and who can file an appeal on the authorization appeals and claims appeals pages.
Applied behavior analysis (ABA) providers interested in joining the network, must complete and return via fax or U.S. mail the Network ABA Provider Participation Packet, which includes an ABA-specific Provider Participation Agreement, the Provider Information Form and IRS Form W-9.
ABA providers who wish to become a non-network provider must complete an ABA Provider Application, located on our Non-Network Applications page.
It can take HNFS 60 to 90 days to credential a network ABA provider based upon the accuracy of the information provided.
It can take HNFS up to 21 days from the date we receive a completed application to certify a behavior technician.
It can take up to 30 days to process a non-network provider application.
You can use our Update Specialty tool to change your credentialing level.
No. Board Certified Behavior Analysts (BCBAs), Board Certified Assistant Behavior Analysis (BCaBAs), BCBA-doctorals (BCBA-Ds) and licensed applied behavior analysis (ABA) providers do not require a Medicare number.
Behavior technicians (BTs) can use our online Check Credentialing Status tool to check provider status.
While BTs are certified and not credentialed, HNFS verifies certification upon receipt of a network application. Please wait a minimum of 21 calendar days following submission of a completed application or group roster to use the Check Credentialing Status tool.
Claims will be paid based on the approval date shown in the tool. BTs must be verified by HNFS as certified prior to seeing TRICARE patients.
Providers can use our Prior Authorization, Referral and Benefit Tool to find out if an authorization or referral is required.
Providers are required to submit authorization and referral requests online. Learn more by visiting our How to Submit a Request for an Authorization or Referral page.
We recommend you register, as it is fast, simple and secure. Registration provides quick and easy access to tools such as authorization submission and status, claims submission, set up electronic funds transfer and view remits. If you choose not to register, you can still submit authorizations and referrals online using our Web Authorization/Referral Tool, which does not require an account.
HNFS processes routine requests within 2–5 business days and medically urgent requests in an expedited manner using the clinical information provided by the health care provider.
You can check the status of requests and view copies of determination letters online (log in to the Secure Portal), or use the automated self-service tools at 1-844-866-WEST (1-844-866-9378).
Our Online Submission Guide and video tutorial provide step-by-step instructions to help you submit your requests.
Submitting an authorization or referral request online through CareAffiliate is fast and secure, and allows you to submit your request and check the status of that request at your convenience. There will be times you will receive an immediate response to your request once submitted.
Some tips include:
- Use Google Chrome for best results.
- Clear your internet cookies regularly.
- The associated CPT code(s), number of visits and duration of the authorization will populate based on the request type selected.
- If you do not have a specific servicing provider in mind, enter the provider specialty and Health Net Federal Services will locate one for you.
- We offer a step-by-step guide to assist you, as well as live and recorded webinars.
Visit our prior authorizations and referrals page for detailed information on guidelines, submissions, and checking prior authorization and referral status.
HNFS will first attempt to coordinate requests for specialty care, inpatient admissions or procedures requiring approval for TRICARE Prime beneficiaries who live near a military hospital or clinic. Therefore, if the provider submits a prior authorization or referral request, the beneficiary may be referred to the military facility for care, regardless of whether a civilian network provider is requested. If the services are not available at the military hospital or clinic, the care will be coordinated with a TRICARE network provider.
Visit our Referrals to Military Hospitals and Clinics page for more information.
Any denied authorization can be appealed. However, the following cannot be appealed:
- Authorizations approved under point of service.
- Authorizations redirected and approved to a network provider when a non-network provider was requested.
- Authorizations redirected and approved to a military treatment facility.
Learn how to file an appeal on our authorization appeals page.
When submitting an authorization or referral request online through Care Affiliate®, you can add attachments and supporting documentation to your request. Our Online Submission Guide walks you through the process.
You can make changes to your processed prior authorization or referral online. Visit our Requesting Prior Authorization or Referral Changes page to learn more.
Providers can determine benefit coverage with the following resources:
Costs will depend on the beneficiary's TRICARE plan and the service. Learn more about costs on the copayments and cost-share information page.
Providers can refer a patient to case management by completing a case management referral. Learn more on our case management page.
You can check the status of your claims online by logging in to our Secure Portal. In order to view status information, the National Provider Identifier (NPI) on your www.tricare-west.com account must match the billing NPI on the claim.
If you do not have a www.tricare-west.com account, use the automated self-service tools at 1-844-866-WEST (1-844-866-9378).
There are specific guidelines regarding TRICARE and other health insurance. Visit the How TRICARE Works with Other Health Insurance page.
You should receive an Explanation of Benefits (EOB) which will explain why a claim was denied. You can view your EOB online (log in required).
Before delivering care, network providers must notify TRICARE patients if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services. The Request for Non-Covered Services form can be used to document the specific services, dates, estimated costs, and other information. If the beneficiary does not sign a Request for Non-Covered Services form or equivalent, you are financially responsible for the cost of non-covered services you deliver.
Hold Harmless Policy for Network Providers
A network provider may not bill a TRICARE beneficiary for services not covered, except in the following circumstances:
- If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary.
- If the beneficiary was informed that services were not covered and agreed in advance and in writing to pay for the services.
Hold Harmless Policy for Non-Network Providers
Non-network providers should also inform beneficiaries in advance if services are not covered. Although not required, non-network providers are strongly encouraged to use a Request for Non-Covered Services form or their own office equivalent to document payment agreements.
Claims can be recouped for various reasons, including, but not limited to:
- Loss of eligibility
- Claim processed without other health insurance information
- Erroneous payment of a non-covered service
- Review of the medical records does not show medical need for the service
The recoupment reason is listed on the recoupment letter or on an attached list of claims. If the recoupment is because the service is not covered under TRICARE or not medically necessary, then appeal rights are given in the recoupment letter.
XPressClaim allows you to submit claims online and often receive instant payment results. Visit our XPressClaim page to learn more.
Online claims submissions allow you to receive faster payments and reduce errors. Visit our Claims Submission page to learn more.
TRICARE network providers must file their patients’ TRICARE claims with Health Net Federal Services/PGBA, even if a patient has other health insurance (OHI). All network provider claims must be filed electronically.
Non-network providers are encouraged to take advantage of the electronic claims features available through Health Net Federal Services and PGBA.
For more information, view our Claims Submission page.
Medicare Bonus Payments: Physicians (MDs and DOs), podiatrists, oral surgeons, and optometrists who qualify for Medicare bonus payments in Health Professional Shortage Areas (HPSAs) may be eligible for a 10 percent bonus payment for claims submitted to TRICARE. The only mental health care providers who are eligible for HPSA bonuses are MDs and DOs.
Performance-Based Maternity Payments: Hospitals who participate in an annual survey managed by The Leapfrog Group may be eligible for up to a 3 percent incentive payment based on reported hospital performance against nationally-recognized benchmarks for maternity care. This is part of TRICARE’s Performance-Based Maternity Payment Pilot, and the Defense Health Agency is responsible for calculating incentive payments.
You may visit the Defense Health Agency's website for current TRICARE allowable charges, also referred to as CHAMPUS Maximum Allowable Charges (CMAC).
Non-participating TRICARE non-network providers can bill up to 115 percent of the CMAC.
CPT is a registered trademark of the American Medical Association. All rights reserved.
PGBA’s proprietary electronic claims system for filing secondary claims with Medicaid can assist in facilitating the flow of claims between TRICARE and Medicaid, and significantly reduce the amount of paperwork required when large batches are submitted. Contact PGBA's EDI help desk at 1-800-259-0264 for more information.
When submitting time units for anesthesia, include the number of minutes on electronic claims or start and stop times on paper claims.
Uniformed Services identification cards contain two numbers assigned by the Department of Defense (DoD):
- The DoD Benefits Number (DBN), which is an 11-digit number found on the back of the ID card that can be used to verify eligibility and file TRICARE claims.
- A DoD ID number, which is a 10-digit number found on the front of the ID card. The 10-digit DoD ID number should not be used when submitting TRICARE claims. If the DoD ID number is used, the claim will be denied or returned.
If your office requires the Social Security number (SSN) of the insured for claims filing, make sure the SSN used is the insured service member's and not the family member’s.
When a beneficiary has both Medicare and TRICARE, the beneficiary is considered dual eligible. His or her TRICARE option is called TRICARE For Life and claims are handled by Wisconsin Physicians Service (WPS) – Military and Veterans Health.
Eligibility guidelines differ due to rules regulating Medicare Part A, Medicare Part B and TRICARE For Life.
For more information visit tricare.mil/medicareeligible.
In most cases, when Medicare serves as the primary payer, providers do not need to get prior authorizations or referrals from Health Net Federal Services, LLC. Visit our Authorizations page to learn more about exceptions. If the beneficiary has exhausted his or her Medicare coverage, or the service is covered by TRICARE but not Medicare, the beneficiary may need a prior authorization or referral from Wisconsin Physicians Service (WPS) – Military and Veterans Health.
In most cases, Medicare serves as primary payer and TRICARE as secondary payer, except when:
- Medicare does not offer coverage or the Medicare benefit has been exhausted, TRICARE will be the only payer and the beneficiary will be responsible for applicable deductibles and cost-shares.
- Medicare offers coverage and TRICARE does not, Medicare serves as the only payer and the beneficiary will be responsible for applicable deductibles and cost-shares.
- Neither Medicare nor TRICARE offer coverage, beneficiaries are responsible for the entire bill.
If the beneficiary has other health insurance (OHI) as well as Medicare and TRICARE, TRICARE will pay after Medicare and the OHI. Once Medicare and the OHI have processed the claim, the beneficiary should file a TRICARE claim with WPS.
Read more about TRICARE and OHI guidelines on our Other Health Insurance page.
Providers should file claims with Medicare first. Medicare will then forward the claim to WPS after Medicare has paid its portion of the claim.
For more information visit WPS’s website or the Defense Health Agency's TRICARE For Life page.
Providers must verify patient eligibility online (log in to the Secure Portal) or through the automated self-service tools at 1-844-866-WEST (1-844-866-9378).
Yes, it is OK to copy military ID cards or Common Access Cards (CACs). It is recommended providers copy both sides of the ID card or CAC to assist in eligibility verification and for the purpose of rendering care.
A valid ID card or CAC alone is not sufficient to prove eligibility; providers must verify eligibility online (log in to the Secure Portal) or through the automated self-service tools at 1-844-866-WEST (1-844-866-9378).
HNFS will notify you once credentialing is completed. You can also check your credentialing status or last credentialing effective date using our Check Credentialing Status tool.
Once HNFS receives your completed provider agreement package, it can take 60 to 90 calendar days to credential a provider based upon the accuracy of the information provided. If you are currently undergoing initial credentialing or re-credentialing, please make sure your CAQH profile is current and you have authorized HNFS to access your profile. Credentialing and re-credentialing are valid for three years.
Note: Credentialing status is different than network status. Please refer to your Provider Participation Agreement for network status and effective date. (If your group has a delegated credentialing agreement, contact your group’s credentialing department for your contract execution date. Otherwise, contact HNFS should you have questions.
You can update your address, phone number or fax number by using the Provider Demographics Update tool. If you have more than 20 providers and/or locations that require an update, please use our TRICARE Provider Group Roster.
It can take HNFS 21 days to review and publish updates based upon the accuracy of the information provided.
In order to update your specialty information, first make sure your information is listed correctly in the National Plan & Provider Enumeration System (NPPES). If correct, use our Update Specialty Tool to request specialty changes.
Behavior technicians updating their specialty to BCBA, BCaBA, BCBA-D or QASP must submit a Provider Information Form and go through the credentialing process to request changes.
You can update your Tax ID or Social Security number (SSN) by faxing in a completed W-9 with a letter on company letterhead to HNFS. Network provider updates can take up to 21 days and non-network provider updates can take up to 30 days.
To add a provider to your network practice who has been credentialed by Health Net Federal Services, LLC (HNFS) within the last three years:
To add a provider to your network practice who has not been credentialed by HNFS:
To add behavior technicians (BTs) who are currently certified or need to be certified:
It can take HNFS 60 to 90 days to credential a new provider once all completed information is received and up to 21 days for loading certified BTs based upon the accuracy of the information provided.
If your group has a delegated credentialing agreement, see our Delegated Provider page.
You can add a location using the Provider Demographics Update tool. If you have more than 20 locations that require an update, please use our TRICARE Provider Group Roster.
You can remove a provider using our Provider Demographic Update Tool.
If your group has a delegated credentialing agreement, see our Delegated Provider page.
Visit our Mental Health Counselor Provider Requirements page to learn about the requirements.
Network providers serve an important role in TRICARE by complementing the services offered by military hospital and clinics. Network providers are civilian providers of choice for most TRICARE beneficiaries, and as a result, will typically receive higher TRICARE patient volume than non-network providers. A network provider agrees to a negotiated rate as payment in full for services rendered.
The TRICARE West Region is comprised of 21 states: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the Rock Island Arsenal area), Kansas, Minnesota, Missouri, (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (areas of Western Texas only, including Amarillo, Lubbock and El Paso), Utah, Washington, and Wyoming.
HNFS uses CAQH for its provider network application and credentialing process. CAQH is a not-for-profit alliance of the nation’s leading health plans, including HNFS. All providers are required to complete a CAQH online application (and keep their information current), except those located in Idaho, Hawaii, Minnesota, and Washington, as an alternate to CAQH is available. (These states have special circumstances and the credentialing process can be completed with another entity.)
HNFS recognizes that many provider groups have their own credentialing department to verify individual provider requirements such as licensure, education, professional liability insurance, adverse sanctions, etc. If you are a provider group with its own credentialing department, consider expediting the TRICARE West Region network credentialing process by allowing HNFS to delegate credentialing to you. This will allow HNFS to use the credentialing data you have already collected, which can be submitted to HNFS in an electronic format.
By delegating the majority of the credentialing process to the provider group, rather than HNFS, the credentialing process is streamlined. Groups are able to submit practitioners on a TRICARE Provider Group Roster (rather than individual Provider Information Forms), which allows for a quicker turnaround time to get practitioners through the network approval process and loaded into HNFS’ systems.
See also our Delegated Credentialing fact sheet.
Once approved by HNFS’ Credentialing Committee, HNFS will request a full and up-to-date provider roster from the group. Visit our Delegated Provider page for more information.
To become a TRICARE non-network provider, you must meet TRICARE regulations and licensing requirements according to your area of health care and the state in which you practice. Visit our Becoming a Non-Network Provider page to learn more and complete an application.
Certification is a one time process. There is no on-going certification process once you become a TRICARE non-network provider.
Most TRICARE non-network providers are not required to sign an agreement. Visit our Becoming a Non-Network Provider to learn more.
Yes. Mental health care providers must meet specific qualifications to be considered TRICARE authorized.
For more information, visit our Mental Health Counselor Provider Requirements and Becoming a Non-Network Provider pages.
Medicare participation is not required to be a TRICARE non-network provider.
For Medicare questions, call 1-800-MEDICARE (1-800-633-4227). Visit our Becoming a Non-Network Provider to learn more.
Non-network providers can update demographics by submitting a Non-Network Provider Information Form.
For specialty updates, complete and submit the Non-Network Specialty Information Update Request Form.
- Note: Mental health providers must submit a new non-network certification form to make specialty changes.
For network provider demographic updates, visit our network provider FAQ.
A provider who has not signed a network agreement, but meets TRICARE licensing and certification requirements, and is authorized by TRICARE to provide care to TRICARE beneficiaries. Learn more about becoming a non-network provider on our Becoming a Non-Network Provider page.
A provider who has completed the credentialing process and signed an agreement with Health Net Federal Services, LLC to be part of the network of providers who participate in the TRICARE program. A network provider accepts the negotiated rate as payment in full for services rendered.
For more information, view the TRICARE West Region Provider Handbook.
The Corporate Services Provider Class consists of institutional-based or freestanding corporations and foundations that provide professional, ambulatory or in-home care, as well as technical diagnostic procedures. Some of the specific provider types in this category include:
- cardiac catheterization clinics
- comprehensive outpatient rehabilitation facilities
- diabetic self-management education programs (American Diabetes Association accreditation required)
- freestanding bone marrow transplant centers
- freestanding kidney dialysis centers
- freestanding magnetic resonance imaging centers
- freestanding sleep disorder diagnostic centers
- home health agencies (pediatric or maternity management required)
- home infusion
- independent physiological laboratories
- radiation therapy programs
Visit our I forgot or lost my password or I forgot my username pages for assistance. You can also contact our Web support line at 1-800-440-3114, Monday–Friday, 6:30 a.m.–7:00 p.m., Pacific time. You can still submit authorizations and referrals online using our Web Authorization/Referral Tool, which does not require a www.tricare-west.com account.