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TriWest
TriWest Healthcare Alliance (TriWest) is contracted with the U.S. Department of Defense for the administration of the TRICARE program in the West Region. The TRICARE program is a health entitlement program for active duty and retired members of the military as well as their eligible dependents.  TriWest is an alliance of shareholder companies, including Regence and other BlueCross and BlueShield Plans and two large university health systems.  TriWest subcontracts panel development and maintenance activities to TriWest shareholder companies, including Regence. Regence is also responsible for assisting and training network providers.
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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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