TRICARE® West Region Provider Handbook Your guide to TRICARE programs, policies and procedures January 1–December 31, 2021 An Important Note about TRICARE Program Information This TRICARE West Region Provider Handbook will assist you in delivering TRICARE benefits and services. At the time of publication, January 1, 2021, the information in this handbook is current. It is important to remember that TRICARE policies and benefits are governed by public law, federal regulation and the Government’s amendments to Health Net Federal Services, LLC’s (HNFS’) managed care support (MCS) contract. Changes to TRICARE programs are continually made as public law, federal regulation and HNFS’ MCS contract are amended. For up-to-date information, visit www.tricare-west.com. Contracted TRICARE providers are obligated to abide by the rules, procedures, policies and program requirements as specified in this TRICARE West Region Provider Handbook, which is a summary of the TRICARE regulations and manual requirements related to the program. TRICARE regulations are available on the Defense Health Agency (DHA) website at www.tricare.mil. If there are any discrepancies between the TRICARE West Region Provider Handbook and TRICARE manuals (Manuals), the Manuals take precedence. Using This TRICARE West Region Provider Handbook This TRICARE West Region Provider Handbook has been developed to provide you and your staff with important information about TRICARE, emphasizing key operational aspects of the program and program options. This handbook will assist you in coordinating care for TRICARE beneficiaries. It contains information about specific TRICARE programs, policies and procedures. TRICARE program changes and updates may be communicated periodically through TRICARE Provider News and the online publications. The TRICARE West Region Provider Handbook is updated annually and as required. Thank you for your service to America’s heroes and their families. TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Photos courtesy of Shutterstock.com HH0920x200 (11/20) Table of Contents SECTION 1 Welcome to TRICARE® and the West Region What Is TRICARE? ..........................................................................................................................................................1 Your Regional Contractor ...............................................................................................................................................1 TRICARE Regions ............................................................................................................................................................1 HNFS TRICARE Contract Administration ........................................................................................................................1 HNFS Website ................................................................................................................................................................2 Online Network Provider Directory ...............................................................................................................................2 HNFS Customer Service Line ..........................................................................................................................................4 Provider Relations Representatives ...............................................................................................................................4 TRICARE Provider News .................................................................................................................................................4 Choosing Wisely® ...........................................................................................................................................................6 Healthcare Effectiveness Data and Information Set (HEDIS) .........................................................................................6 National Disaster Medical System (NDMS) ....................................................................................................................7 SECTION 2 Important Provider Information TRICARE Policy Resources ..............................................................................................................................................8 Health Insurance Portability and Accountability Act of 1996 ........................................................................................8 TRICARE Provider Types ...............................................................................................................................................10 Accepting Patients from the U.S. Department of Veterans Affairs ..............................................................................11 Military Hospitals and Clinics ......................................................................................................................................11 Urgent Care..................................................................................................................................................................11 Emergency Care ...........................................................................................................................................................12 Corporate Services Provider Class ...............................................................................................................................12 Managing the Network ................................................................................................................................................13 Provider Certification and Credentialing .....................................................................................................................13 Value-Based Incentives ................................................................................................................................................15 Network Provider Responsibilities ...............................................................................................................................15 Updating Provider Information ....................................................................................................................................20 Beneficiary Rights and Responsibilities .......................................................................................................................21 An Important Message from TRICARE .........................................................................................................................21 S EC T I O N 3 TRICARE Eligibility Verifying Eligibility .......................................................................................................................................................22 Same-Sex Spouses .......................................................................................................................................................24 TRICARE and Medicare Eligibility .................................................................................................................................24 Eligibility for TRICARE and Veterans Affairs Benefits ...................................................................................................24 TRICARE Health Care Program Options .......................................................................................................................24 TRICARE Prime Coverage Options................................................................................................................................24 TRICARE Select .............................................................................................................................................................26 TRICARE Young Adult ...................................................................................................................................................26 Direct-Care Only ..........................................................................................................................................................26 TRICARE For Life...........................................................................................................................................................26 TRICARE for the National Guard and Reserve ..............................................................................................................27 TRICARE Pharmacy Program ........................................................................................................................................28 TRICARE Dental Options ..............................................................................................................................................31 Cancer Clinical Trials ....................................................................................................................................................32 TRICARE Extended Care Health Option .......................................................................................................................32 Supplemental Health Care Program ............................................................................................................................34 Transitional Health Care Benefits ................................................................................................................................35 S EC T I O N 4 Medical Coverage Network Utilization