Provider Certification

Becoming a Certified TRICARE Provider

Benefits of becoming a network provider: As always, beneficiaries who seek care with a TRICARE network provider enjoy significant cost savings. Becoming a network provider may also bring with it a higher volume of patients; TRICARE refers 98% of patients to the TRICARE network for care if the services are not available at a Military Treatment Facility. Find out today how to become a TRICARE-certified network provider.

Becoming a non-network Provider: Providers who are willing to see TRICARE patients as a non-network provider must become TRICARE-certified. Non-network (certified) providers may choose to accept TRICARE's allowable amount as payment in full for covered benefits with associated cost shares and deductibles. If a TRICARE-certified provider chooses not to accept the TRICARE allowable amount as payment in full, there is a limit to how much a patient may be billed (115% of the TRICARE allowable amount).
TRICARE will only pay claims to providers who are TRICARE network or TRICARE-certified (non-network) providers.

How to certify as a TRICARE non-network provider

There are two ways a provider can become TRICARE-certified:

Submit a claim
Submit a certification packet

See below for more information on both methods.

Claims Submission prior to Certification

If you are already a Medicare-certified provider and you want to be a TRICARE-certified provider, all you need to do is file a claim with Wisconsin Physicians Service (WPS), TriWest's claims processor. WPS will take the information from your claim form and verify your Medicare-certification. Once verified, you are then designated as a TRICARE-certified provider.*

Important information about submitting a claim prior to becoming TRICARE-certified:

A non-certified provider may submit their claim electronically after registering for the secure Web site at www.triwest.com/provider and completing an EDI agreement with WPS. Go to Find a Form and download the EDI Agreement form now. This is the fastest, easiest way to become certified.
If all pertinent provider information is included with an electronic claim and no additional information is required, WPS staff can complete the certification process in as little as an hour once they begin the review.
If the provider bills under multiple Tax Identification Numbers or has multiple addresses, additional information may be needed for provider certification. WPS may request additional information through various methods. This may include sending out information packets after a phone call has been made to the provider. Please allow for more time for your submission to process if you fit this scenario.
Due to the short time-frame necessary for WPS to certify a provider, there is no need for any priority handling, special treatment, or forms.
WPS does not need the provider's signature on the claim to complete certification because the submission of an electronic claim serves that purpose.
WPS does not need the provider to call prior to submitting a claim, unless the provider is calling for assistance in getting set up for EDI submission.
Providers who wish to become certified by submitting an electronic claim should first do the following:
- Register for the secure provider Web site. Call WPS EDI at (800) 782-2680 if you need assistance in registering or in determining the best EDI option for you.
- If you submit claims via a clearinghouse, claims submission software, or other electronic means, go to the Find a Form tab on www.triwest.com/provider
  - Download the TriWest Provider EDI Agreement form, if using the claim submission tool available in the secure area of www.triwest.com/provider

* See Exceptions below.

Exceptions to Claims Submission Prior to Certification

Skilled Nursing Facilities must complete a certification packet and sign a Skilled Nursing Facility Certification form in order to become certified. You may download a Skilled Nursing Facility Certification form from the Find a Form tab on this web site.
Partial Hospitalization Programs (PHPs), Residential Treatment Centers (RTCs), and Substance Use Disorder Rehabilitation Facilities (SUDRFs) must be TRICARE-certified. Providers should contact Maximus by calling (602) 308-7160, e-mail at nqmc@maximus.com, or by mail at:

NQMC - Maximus
600 E. Northern Avenue, #100
Phoenix, AZ 85020
Providers in Alaska should complete a certification form. If claims are submitted by an Alaskan non-certified provider, WPS will fax the appropriate certification form to the provider and request that the certification form be completed, signed and returned to WPS within three days.
Providers who are not Medicare-certified should complete a certification form.

If a provider prefers to submit a certification packet.

Providers can download and print a certification packet, complete the form, and mail or fax the forms to WPS. Certification forms can be found at www.triwest.com/provider under the Find a Form tab.
This process will take LONGER to complete than submitting a claim.
Submitting on paper may lead to unnecessary delays due to mailing forms to the provider, time to complete the paperwork, and mailing time to return the documents to WPS.
Online submission of certification requests via the Internet is not available at this time.