Tricare Prior Authorization & Billing Guide

Tricare covers approximately 9.6 million beneficiaries -- active-duty service members, retirees, their families, and survivors. For healthcare organizations near military installations or in communities with significant veteran and military populations, Tricare can represent a substantial payer mix segment. Yet Tricare billing consistently ranks among the most confusing payer processes for revenue cycle teams, largely because Tricare operates differently from both commercial insurance and Medicare in ways that are not always intuitive.

Tricare is administered by the Defense Health Agency (DHA) and delivered through regional managed care support contracts. The program has its own fee schedule (CMAC), its own authorization requirements, its own claim submission pathways, and its own rules about what constitutes timely filing, acceptable modifiers, and valid appeal grounds. Teams that treat Tricare as "just another commercial payer" encounter preventable denials, delayed reimbursement, and compliance issues.

This guide covers the Tricare plan landscape, prior authorization and referral requirements, claim submission procedures, reimbursement structure, common denial patterns, appeal processes, and the specific billing rules that distinguish Tricare from commercial and Medicare billing.

Tricare Plan Types

Understanding the plan landscape is essential because authorization requirements, cost-sharing, and billing procedures differ by plan type.

Tricare Prime

Who it covers: Active-duty service members (ADSM), active-duty family members who enroll, and retirees and their families who enroll. ADSMs are automatically enrolled in Tricare Prime.

How it works: HMO-style managed care. Beneficiaries are assigned a Primary Care Manager (PCM) -- either at a military treatment facility (MTF) or a civilian network provider. Referrals and authorizations are required for most specialty and inpatient care.

Cost-sharing: ADSMs have no cost-sharing. Family members have nominal copays. Retirees and their families have annual enrollment fees, copays, and cost-shares that are higher than active-duty family rates but generally lower than commercial insurance.

Billing implications: Referral from the PCM is required before the beneficiary sees a specialist. Without a valid referral, the claim will be denied or processed as a point-of-service (POS) claim at a significantly higher cost to the beneficiary.

Tricare Select

Who it covers: Active-duty family members, retirees and their families, and certain other eligible beneficiaries who choose not to enroll in Prime.

How it works: PPO-style plan. Beneficiaries can see any Tricare-authorized provider without a referral. In-network and out-of-network cost-sharing tiers apply.

Cost-sharing: Annual deductibles, copays or cost-shares for covered services, and catastrophic caps. Costs are lower for in-network providers than out-of-network. Group A (active-duty family) rates are lower than Group B (retiree family) rates.

Billing implications: No referral required, but prior authorization is still required for certain services. The distinction between referral and authorization is important in Tricare and is a common source of confusion.

Tricare Reserve Select (TRS)

Who it covers: Selected Reserve members and their families.

How it works: Similar to Tricare Select, with monthly premiums. PPO-style with in-network and out-of-network options.

Billing implications: Same claim submission process as Tricare Select. Verify TRS enrollment specifically -- Reserve members may not be eligible for TRS during periods when they are on active-duty orders (they would be covered under Tricare Prime during activation).

Tricare Young Adult (TYA)

Who it covers: Unmarried adult children of eligible sponsors, up to age 26. Similar to the ACA dependent coverage provision.

How it works: Available as TYA Prime or TYA Select, with monthly premiums.

Billing implications: Verify the specific TYA plan type (Prime vs. Select) as referral and authorization requirements differ. TYA is a separate plan from the sponsor's Tricare coverage.

Tricare for Life (TFL)

Who it covers: Military retirees and their family members who are Medicare-eligible (typically age 65+) and enrolled in Medicare Part A and Part B.

How it works: Tricare for Life acts as a supplement to Medicare. Medicare pays first, and TFL covers most remaining out-of-pocket costs. TFL is automatic -- no enrollment is required beyond maintaining Medicare Part A and Part B.

Billing implications: Bill Medicare first. TFL covers the Medicare deductible and coinsurance in most cases. Claims cross over from Medicare to TFL automatically through the Medicare-Tricare crossover process. Do not bill TFL directly for services that should go through Medicare first.

Tricare Retired Reserve (TRR)

Who it covers: Retired Reserve members (those who have retired from the Reserves but are not yet age 60 and do not qualify for retired pay). Available with monthly premiums.

Billing implications: Similar to Tricare Select billing. Verify TRR eligibility carefully -- this population has specific eligibility windows.

Tricare vs. Commercial Insurance: Key Billing Differences

Factor	Commercial Insurance	Tricare
Fee schedule	Negotiated contracted rates	CMAC (CHAMPUS Maximum Allowable Charge)
Network	Insurer-specific networks	Tricare network managed by regional contractors
Referral requirement	Varies by plan (HMO vs. PPO)	Prime requires referrals; Select does not
Prior authorization	Payer-specific lists	DHA/contractor-specific requirements
Claims submission	Direct to payer	To regional managed care support contractor
Timely filing	Varies (90-365 days)	1 year from date of service
Balance billing	Allowed for OON (with exceptions)	Prohibited for network providers; limited for OON
COB	Standard COB rules	Tricare-specific COB (Tricare is often last payer)
Patient population	General population	Military community (may affect service patterns)
Regulatory framework	State insurance regulations	Federal regulations (32 CFR 199)

Tricare Prior Authorization Requirements

Referral vs. Prior Authorization

Tricare distinguishes between referrals and prior authorizations, and understanding the difference is critical:

Referral: A PCM-generated recommendation for the patient to see a specialist or receive a specific service. Required under Tricare Prime. The referral does not guarantee Tricare coverage -- it authorizes the patient to seek care outside their PCM.

Prior authorization: A formal determination by the regional contractor that the service is medically necessary and covered by Tricare. Required for specific high-cost or specialized services regardless of plan type.

A Tricare Prime patient may need both a referral from the PCM and a prior authorization from the regional contractor for certain services. A Tricare Select patient does not need a referral but may still need a prior authorization.

Services Requiring Prior Authorization

Tricare requires prior authorization for the following categories (this list is not exhaustive and is updated periodically by DHA):

Inpatient services:

All non-emergency inpatient hospital admissions
Inpatient behavioral health admissions
Skilled nursing facility admissions
Inpatient rehabilitation
Substance use disorder residential treatment

Outpatient services:

Advanced imaging (MRI, CT, PET scans) -- through the radiology utilization management program
Selected outpatient surgical procedures
Certain specialty medications and Part B drugs
Durable medical equipment above cost thresholds
Home health services
Certain genetic and molecular testing
Transplant evaluations and procedures
Certain pain management procedures

Behavioral health services:

Inpatient behavioral health
Residential treatment programs
Partial hospitalization programs
Intensive outpatient programs
Applied behavior analysis (ABA) for autism spectrum disorder
Psychological testing (beyond initial assessment)

How to Submit Prior Authorization

Prior authorization requests are submitted to the regional managed care support contractor:

Electronic submission: Through the regional contractor's provider portal (preferred method):

East Region (Humana Military): humana-military.com provider portal
West Region (Health Net Federal Services / TriWest Healthcare Alliance): triwest.com provider portal

Phone submission:

East Region: 1-800-444-5445 (Humana Military provider line)
West Region: 1-844-866-9378 (TriWest provider line)

Fax submission: Available through regional contractor fax numbers (listed on contractor websites). Use fax only when electronic submission is not available.

Authorization Decision Timelines

Request Type	Standard Timeline	Urgent Timeline
Pre-service (non-urgent)	5 business days	N/A
Pre-service (urgent)	N/A	1 business day (24 hours)
Inpatient concurrent review	1 business day	1 business day
Post-service/retrospective	30 calendar days	N/A
Behavioral health inpatient	1 business day	1 business day

Tricare Region and Contractor Table

Region	Contractor	States/Territories Covered	Provider Portal	Provider Phone
East	Humana Military (Humana Government Business)	CT, DC, DE, GA, IL, IN, KY, MA, MD, ME, MI, NC, NH, NJ, NY, OH, PA, RI, SC, TN, VA, VT, WI, WV, and parts of FL, IA, MN, MO, TX	humana-military.com	1-800-444-5445
West	TriWest Healthcare Alliance (Health Net Federal Services)	AK, AZ, CA, CO, HI, ID, KS, LA, MT, ND, NE, NM, NV, OK, OR, SD, UT, WA, WY, and parts of AR, FL, IA, MN, MO, TX	triwest.com	1-844-866-9378
Overseas	International SOS Government Medical Services	All overseas locations	tricare-overseas.com	Varies by location

Note: Some states are split between East and West regions based on zip code. Verify the specific region for each beneficiary based on their residential zip code.

Tricare Reimbursement: CMAC Fee Schedule

Tricare reimburses civilian (non-military) providers based on the CHAMPUS Maximum Allowable Charge (CMAC), which is Tricare's own fee schedule.

How CMAC Is Calculated

CMAC rates are derived from the Medicare fee schedule but are not identical to it:

CMAC is generally based on the Medicare Physician Fee Schedule with geographic adjustments
DHA updates CMAC rates annually
For some services, CMAC rates may be higher or lower than Medicare rates
CMAC includes separate rates for institutional (facility) and professional claims

Network vs. Non-Network Reimbursement

Network (participating) providers:

Accept CMAC as payment in full
Cannot balance bill the beneficiary beyond applicable cost-sharing
Claims are submitted to the regional contractor
Payment is typically issued within 30 days for clean electronic claims

Non-network (non-participating) providers:

Reimbursement is based on CMAC or the billed charge, whichever is lower
May balance bill the beneficiary up to 15% above the CMAC rate (for Tricare Select out-of-network services) in most cases
Balance billing limits vary -- active-duty family members cannot be balance billed in some circumstances
Non-network claims may take longer to process

Reimbursement Comparison

Service Type	Medicare Rate (Example)	CMAC Rate (Approximate)	Notes
Office visit (99213)	$110	$105-$115	CMAC closely tracks Medicare
Office visit (99214)	$160	$155-$170	Varies by locality
MRI without contrast	$350	$340-$375	Facility and professional components
Colonoscopy (45378)	$380	$370-$400	Screening colonoscopy may differ

Rates are approximate and vary by geographic locality. Providers should verify current CMAC rates through the regional contractor or the DHA CMAC search tool.

Tricare Modifiers and Special Billing Rules

Tricare-Specific Modifier Requirements

Tricare follows standard CPT/HCPCS modifier usage but has some specific requirements:

Modifier AH, AJ, AK: Used to identify services provided by clinical psychologists (AH), clinical social workers (AJ), and clinical nurse specialists (AK). Tricare requires these modifiers for behavioral health claims.
Modifier AT: Required for chiropractic services to indicate active treatment. Tricare covers chiropractic care for active-duty service members only (unless authorized under the expanded chiropractic program).
Modifier QK, QX, QY, QZ: Anesthesia supervision modifiers follow standard CMS rules, but Tricare has specific CRNA supervision policies that differ from some commercial payers.
Modifier TD: Used for RN First Assistant services during surgery when billed separately.

Tricare-Specific Billing Rules

Active-duty service member services: ADSMs should not be billed any patient responsibility. Their cost-sharing is zero. If your system generates a patient statement for an ADSM, it indicates a billing configuration error.

Preventive care: Tricare covers preventive services based on the DHA Clinical Preventive Services schedule, which generally follows USPSTF recommendations. No cost-sharing applies to covered preventive services.

Maternity care: Tricare covers maternity care with specific billing rules for global obstetric packages. Authorization is required for deliveries at non-network facilities.

Mental health parity: Tricare follows federal mental health parity requirements. Cost-sharing for behavioral health services should be at parity with medical/surgical services.

Pharmacy benefits: Tricare pharmacy benefits are administered through Express Scripts. Medical benefit drugs (Part B equivalent) are billed through the medical claim. Self-administered medications are covered through the pharmacy benefit and billed through Express Scripts.

Tricare Dental Program (TRDP)

Tricare dental coverage for active-duty family members is provided through the Tricare Dental Program (TRDP), administered by United Concordia Companies, Inc.

Key TRDP billing points:

TRDP is a separate program from Tricare medical -- dental claims go to United Concordia, not to the regional managed care contractor
TRDP covers preventive, basic, and major dental services with different cost-sharing tiers
Annual maximum benefit applies
No prior authorization is required for most preventive and basic services
Prior authorization may be required for orthodontic services, major restorative, and prosthodontic services
Active-duty service members receive dental care through military dental clinics and are not covered under TRDP

TRDP claims submission: Submit dental claims to United Concordia using the ADA dental claim form or EDI transaction. United Concordia payer ID: 86027.

Tricare Pharmacy Benefits

Tricare pharmacy benefits are administered by Express Scripts and operate separately from the medical benefit:

Pharmacy benefit tiers:

Military pharmacies: No cost to the beneficiary
Tricare mail-order pharmacy: Lowest cost-sharing for maintenance medications
Retail network pharmacies: Moderate cost-sharing
Non-network retail pharmacies: Highest cost-sharing

Prior authorization for pharmacy: Required for select medications, including specialty drugs, non-formulary medications, and certain brand-name drugs when generics are available. Pharmacy prior auth is submitted through Express Scripts, not through the regional managed care contractor.

Medical benefit drugs: Drugs administered in a healthcare setting (infusions, injections) are covered under the medical benefit and billed through the regional contractor. These are subject to the medical prior authorization process, not the pharmacy prior authorization process.

Common Tricare Denial Reasons

1. No Referral on File (Tricare Prime)

The most common Tricare Prime denial. The beneficiary saw a specialist without a referral from their PCM. The claim denies or processes at the point-of-service rate with significantly higher beneficiary cost-sharing.

Prevention: Verify Tricare Prime enrollment during eligibility verification and confirm that a valid referral is on file before the appointment. The referral should be active (not expired) and cover the specific service type.

2. Prior Authorization Not Obtained

A service requiring prior authorization was rendered without obtaining approval from the regional contractor.

Prevention: Check authorization requirements for the specific service and plan type before rendering the service. Submit authorization requests through the regional contractor's portal.

3. Timely Filing Exceeded

The claim was submitted more than 1 year from the date of service.

Prevention: While 1 year is generous compared to many commercial payers, claims should be submitted promptly. Implement claim submission tracking to flag aging unbilled claims.

4. Provider Not Tricare-Authorized

The rendering provider is not authorized by Tricare to provide care to Tricare beneficiaries. Tricare authorization is separate from Medicare enrollment and commercial payer credentialing.

Prevention: Verify Tricare authorization status for all providers who treat Tricare patients. Maintain current Tricare provider authorization through the regional contractor.

5. Service Not Covered

Tricare does not cover certain services that commercial plans may cover, including some cosmetic procedures, custodial care, and services considered experimental or investigational by DHA.

Prevention: Verify service coverage before rendering. Tricare's covered services are defined in 32 CFR 199 and the Tricare Policy Manual.

6. Incorrect Claim Routing

The claim was submitted to the wrong regional contractor or to the wrong Tricare program.

Prevention: Verify the beneficiary's region based on their residential zip code and submit to the correct regional contractor. For TFL patients, bill Medicare first.

7. Coordination of Benefits Issues

Tricare is the last payer in most COB situations. If the beneficiary has other health insurance (OHI) through an employer, that insurance must be billed first.

Prevention: Verify OHI during eligibility verification. Tricare requires providers to bill other insurance before billing Tricare. Claims submitted to Tricare without evidence of primary payer billing may be denied.

Tricare Appeal Process

Filing an Appeal

Timeframe: Appeals must be filed within 90 days of the date on the Explanation of Benefits (EOB) or remittance advice.

Where to file: Appeals are submitted to the regional managed care support contractor (Humana Military for East Region, TriWest for West Region).

How to file:

Written appeal: Preferred method. Include the beneficiary's name, sponsor's SSN or DoD Benefits Number, date of service, explanation of why the denial should be overturned, and supporting documentation.
Online: Through the regional contractor's provider portal

Appeal Levels

Initial reconsideration: The regional contractor reviews the appeal. Decision typically within 60 days.
Formal review: If the reconsideration is unfavorable, request a formal review by DHA. Filed within 90 days of the reconsideration decision.
Independent hearing: For claims above a threshold amount (adjusted annually), an independent hearing before a hearing officer. Filed within 60 days of the formal review decision.
DHA Director review: Final administrative appeal level.

Appeal Success Strategies

Include all clinical documentation supporting medical necessity
Reference Tricare Policy Manual provisions that support coverage
For authorization-related denials, explain why retrospective authorization should be granted (emergency circumstances, referral was in process)
For coding denials, provide documentation supporting the billed codes

How AI Automates Tricare Billing and Authorization

Tricare billing requires managing multiple plan types, two regional contractors, referral and authorization distinctions, CMAC reimbursement rates, and Tricare-specific billing rules -- all of which differ from commercial and Medicare processes. AI automation handles this complexity.

Automated Plan Type Detection

AI identifies the specific Tricare plan type (Prime, Select, TRS, TYA, TFL) during eligibility verification and applies the correct billing rules, referral requirements, and authorization procedures for that plan type.

Referral and Authorization Management

AI distinguishes between referral requirements (Prime only) and prior authorization requirements (all plan types for certain services), ensuring both are obtained when needed. The system tracks referral validity (dates, visit counts, service types) and flags expirations.

Regional Contractor Routing

AI routes claims and authorization requests to the correct regional contractor based on the beneficiary's residential zip code, preventing incorrect routing denials.

CMAC Rate Monitoring

AI compares Tricare payments against CMAC rates, identifying underpayments and potential balance billing opportunities (for non-network claims where permitted).

COB Automation

AI identifies beneficiaries with other health insurance (OHI) and ensures the primary payer is billed first, preventing Tricare COB denials. For TFL patients, AI ensures Medicare is billed first with automatic TFL crossover.

Internal Link References:

Prior Authorization Automation Guide
Eligibility Verification Best Practices
How AI Reduces Denial Rates
Complete Guide to Healthcare Denial Management
Coordination of Benefits Guide
Workers Comp and Auto Insurance Billing
Medicare Eligibility Verification Guide

QuickIntell automates Tricare billing across all plan types and both regional contractors. From referral tracking and prior authorization to CMAC rate monitoring and COB coordination, QuickIntell ensures clean Tricare claims and maximum reimbursement. See how QuickIntell handles Tricare billing for your organization.