| There are three TRICARE options
available for eligible beneficiaries: Standard, Extra,
and Prime.
- TRICARE Standard is similar to a traditional indemnity
plan with cost sharing and an annual deductible
- TRICARE Extra is similar to a preferred provider
organization (PPO)
- TRICARE Prime is similar to a health maintenance
organization (HMO)
For benefit information, please call 1 (888) TRIWEST
(874-9378).
Claims, billing and reimbursement
Hospitals are reimbursed according to TRICARE’s
diagnosis-related group (DRG) based payment methodology
and Medicare guidelines with the exception of sole
community hospitals which are reimbursed based on billed
charges. Physicians and ancillary providers are paid
according to a fee schedule called Champus Maximum
Allowable Charge (CMAC).
TriWest has partnered with Wisconsin Physicians Service
Insurance Corporation (WPS) to process and pay claims.
For claims related questions, please call WPS at 1
(888) 874-9378. For questions related to Electronic
Data Interchange (EDI), please call the WPS EDI department
at 1 (800) 782-2680 (option 2).
Prior Authorization
TriWest requires prior authorization for some services.
The current Prior Authorization List (PAL)
is available on the TriWest Web site at www.triwest.com.
- Referrals (only required for members with
TRICARE Prime coverage)
When a primary care manager or specialist is unable
to provide a specialized medical service, they must
request a referral either from the local TRICARE
service center or TriWest.
Credentialing
TriWest has specific credentialing standards that
are similar to commercial credentialing standards (e.g.
National Committee for Quality Assurance [NCQA] or
the Utilization Review Accreditation Commission).
Training
As a requirement of your contract, you or someone
from your office must complete a TRICARE provider orientation
within 120 days after joining the network. Orientations
are available online at www.triwest.com or
via instructor-led educational seminars. Seminar schedules
are available on the TriWest Web site. You may also
contact your provider
consultant to arrange an orientation in your office
or at a location near you. Orientations cover critical
information including:
- Claims processing guidelines
- Referral/authorization procedures
- Claims status and eligibility procedures
- TRICARE benefit information
- TRICARE Provider Handbook
- Who to contact
Additional TRICARE resources:
Physicians and other health care professionals may
also contact their provider
consultant for
questions. TriWest beneficiaries should contact
TriWest directly at 1-888-TRIWEST (874-9378).
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