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 brings with it a higher volume of patients; TRICARE refers 97.5% 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 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 the 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

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, and they will take the information from your claim form and verify your Medicare-certification. Once verified, you are then designated as a TRICARE certified provider.*

• A non-certified provider may submit their claim electronically after completing an electronic claims agreement with WPS (go to Find a Form and download the electronic claims agreement form now). A claim may also be submitted on paper.
• 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 ID 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 and/or faxing 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.
• The fastest, easiest way to get certified is thru submitting a claim electronically.

* See Exceptions below

Claims Submission prior to Certification

• 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 to get set up for EDI submission.
• Providers can submit claims electronically prior to becoming TRICARE certified IF an EDI agreement with WPS is signed in advance.
• Providers can submit claims electronically without having their 18-digit provider number in advance.
• Providers who wish to become certified by submitting an electronic claim should first do the following:
• Call WPS EDI at (800) 782-2680, or
• Go to the Find a Form tab
• Download the TriWest Online Claim Submission Agreement form, if using the claim submission tool available on this web site, or
• Download the TriWest Provider EDI Agreement form if you submit claims via a clearinghouse, claims submission software, or other electronic means).

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 under the Find a Form tab on this web site.
• Note: This process will take LONGER to complete than submitting a claim because claims are tracked extensively in the WPS system and providers needing certification will be given higher priority in processing if a claim has been submitted.
• Submitting on paper leads 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.

Exceptions

• Skilled Nursing Facilities must complete a certification packet and sign a participation form in order to become certified. You may download a Skilled Nursing Facilities packet 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 certified by Maximus. Providers should contact Maximus by calling (602) 308-7160, e-mail at nqmc@maximus.com, or by mail at:

  NQMC - Maximus
  1600 E. Northern Avenue, #100
  Phoenix, AZ 85020

• Providers in Alaska should complete a certification form. If claims are submitted by an Alaska non-certified provider, WPS will fax the 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.