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.

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, call 1 (888) 874-9378
• For Electronic Data Interchange (EDI) related questions, 1 (800) 782-2680, option 2

View the TRICARE Program Manuals.

Prior Authorization
TriWest requires prior authorization for some services. View the current Prior Authorization List (PAL).

• Referrals (only required for members with TRICARE Prime coverage)
  When a primary care manager or specialist is unable to provide a specialized medical service, he or she must request a referral either from the local TRICARE service center or TriWest.

Behavioral Health
TriWest Behavioral Health Portal is an online resource to help address the emotional needs of Service members and their families. The Portal offers access to several tools and resources including:

• Assessment tools
• Practice guidelines
  
• TRICARE benefit information
  
• Access to local and national resources

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).

Providers applying for TRICARE must complete the supplemental credentialing questionnaire form per TriWest.

Use the Provider Information Update Form to notify us when:

• A provider leaves your clinic
• A new provider joins your clinic
• Your clinic/practice is no longer in business
• Your clinic/practice no longer accepts new TRICARE patients
  
• One of the following changes:
  • Phone number
  • Clinic/practice address
  • Tax identification or National Provider Identifier number

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.

You may also contact your provider consultant to arrange an orientation in your office or at a location near you.

Additional TRICARE resources:

• TRICARE Management Activity
• TriWest website
• Phone toll free: 1-888-TRIWEST (874-9378) or 1 (602) 564-2161

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).