TRICARE only reimburses appropriate covered services for eligible beneficiaries provided by TRICARE-authorized providers. TRICARE-authorized providers must meet TRICARE licensing and certification standards and must comply with regulations specific to their health care areas. Certified providers are considered non-network TRICARE-authorized providers. Non-network providers may also choose to “accept assignment” (i.e., participate) on a case-by-case basis. If a non-network provider accepts assignment, he or she is considered a participating non-network provider and agrees to accept the TRICARE-allowable charge as payment in full for covered services. Non-participating non-network providers do not have to accept the TRICARE-allowable charge or file claims for beneficiaries.
Providers may see TRICARE patients and file claims with TRICARE to initiate the certification process. All providers must submit certification forms to PGBA to become a TRICARE-certified provider. To download forms, visit myTRICARE
and search for Provider Forms.
Additionally, freestanding Partial Hospitalization Programs (PHPs), Residential Treatment Centers (RTCs), and Substance Use Disorder Rehabilitation Facilities (SUDRFs) must first be certified by KePRO, the TRICARE Quality Monitoring Contractor (TQMC). These providers should call KePRO at 1-877-841-6413 to speak with TRICARE certification representatives and request information. Once KePRO certifies the facility, the provider must complete the ValueOptions, Inc. (ValueOptions) contracting process. Call ValueOptions at 1-800-700-8646 for more information.
Note: Separate TRICARE certification of hospital-based PHPs is not required. When a hospital is a TRICARE-authorized provider, the hospital’s PHP is also considered a TRICARE-authorized provider. However, freestanding PHPs must be certified and enter into a participation agreement with TRICARE and obtain the required authorization prior to admitting patients. Freestanding PHPs that are interested in becoming TRICARE-authorized must contact KePRO.
To join the TRICARE network, a TRICARE-authorized provider must complete the credentialing process and sign a contract with Humana Military or ValueOptions for behavioral health. The credentialing process requires primary-source/acceptable source verification of the provider’s education/training, board certification, license, professional and criminal background, malpractice history, and other pertinent data.To meet the minimum credentialing criteria established by Humana Military, individuals must:
- Have graduated from a school appropriate to their profession, and completed postgraduate training appropriate to their practicing specialty.
- Have a current, valid, unrestricted, and un-probated professional state license* in the state(s) they practice within.
- Have a current, valid, unrestricted, and un-probated Drug Enforcement Agency (DEA) registration, if applicable to their profession/specialty.
- Have a current, valid, unrestricted, and un-probated State Controlled Dangerous Substance registration, if applicable to their profession/specialty and the state they practice within.
- Have current professional liability insurance or meet the state/ local guidelines.
- Be able to participate in federal health care programs.
- Not have been convicted of a felony related to controlled substances, healthcare fraud, or a child or patient abuse.
- Not have any physical or behavioral health condition that cannot be accommodated without undue hardship or without reasonable accommodation.
- Not have untreated chemical/substance dependency.
- Not have any unexplained gaps of six months or more in their work history during the past five years.
*The TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002, CHAPTER 11, SECTION 3.2, STATE LICENSURE AND CERTIFICATION POLICY states, “A. State Licensure/Certification. Otherwise covered services shall be cost-shared only if the individual professional provider holds a current, valid license or certification to practice his or her profession in the state where the service is rendered.
Licensure/certification in a profession other than that for which the provider is seeking authorization is not acceptable. The licensure/certification must be at the full clinical level of practice. Full clinical practice level is defined as an unrestricted license that is not subject to limitations on the scope of practice ordinarily granted all other applicants for similar specialty in the granting jurisdiction. Individuals placed on probation or whose license has otherwise been restricted are not considered to be practicing at the full clinical practice level… ”
Credentialing is also required for acute inpatient facilities, free standing surgical centers, home health agencies, and skilled nursing facilities.
To meet the minimum credentialing criteria established by Humana Military, facilities must:
- Have a current signature/date on the application.
- Have a current, valid, unrestricted, and un-probated state license.
- Have current acceptable liability insurance.
- Be able to participate in federal health care programs including Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan) as reported by the Office of the Inspector General (OIG) or the General Services Administration (GSA).
- Have acceptable accreditation status appropriate to the facility.
The provider must wait to receive final notification of contract execution and credentialing approval from Humana Military before providing care to TRICARE beneficiaries as a network provider. Humana Military monitors each network provider’s quality of care and adherence to DoD, TRICARE, and Humana Military policies. Network providers must be recredentialed at least every three years.
Behavioral health care providers—including freestanding PHPs, RTCs, and SUDRFs—must also be credentialed by ValueOptions. For more information or to apply to join the TRICARE network, call ValueOptions at 1-800-700-8646 or send an email to firstname.lastname@example.org
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