Please review our TRICARE West Region Transition FAQ page for information.
For additional information, visit www.tricare.mil/changes.
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.
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 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.
XPressClaim allows you to submit claims online and often receive instant payment results. Visit our XPressClaim 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.
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.
If you were a network provider with HNFS and you need to update your address, phone number or fax number for claims processing purposes (for dates of service prior to Jan. 1, 2025 ONLY), you can use our Provider Demographics Update tool or contact our customer service team.
If you need to add a location or rendering provider, you must do this with TriWest Healthcare Alliance.
If you need to update your specialty for claims processing purposes (dates of service prior to Jan. 1, 2025 ONLY), please contact us.
If you need to update your Tax ID or SSN for claims processing purposes (dates of service prior to Jan. 1, 2025 ONLY), please contact us.
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.–6:00 p.m., PT.
