Please review our TRICARE West Region Transition page for information.
For additional information, visit www.tricare.mil/changes.
If the date of service is before Jan. 1, 2025, AND the claim was submitted to HNFS by April 30, 2025:
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.
Starting May 1, 2025, check with TriWest on all other claims.
There are specific guidelines regarding TRICARE and other health insurance. Visit the How TRICARE Works with Other Health Insurance page.
You should receive a remittance adivce which will explain why a claim was denied. You can view your remittance advice 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. 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 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.
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.
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.
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.
For claims with dates of service prior Jan. 1, 2025:
We can accept demographic updates via our Provider Demographics Update tool through June 30, 2025. However, it’s important you validate your information with TriWest Healthcare Alliance, the current TRICARE West Region contractor.
Please contact TriWest Healthcare Alliance for non-network provider demographic updates.
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, 8:30 a.m.–5:00 p.m., PT.
