Tricare Provider Credentialing Guidelines

This guide covers everything you need to know about the Tricare credentialing process, from the steps involved to key requirements, challenges, and best practices. However, before we discuss the details, let’s quickly review Tricare insurance!

TRICARE is the Department of Defense’s (DoD) worldwide healthcare program available to eligible beneficiaries of the eight uniformed services. These include the US Army, Navy, Marine Corps, Air Force, Space Force, Coast Guard, Commissioned Corps of the US Public Health Service (USPHS), and Commissioned Officer Corps of the National Oceanic and Atmospheric Administration (NOAA).

Additionally, TRICARE-eligible beneficiaries may include active-duty service members, retired service members, National Guard and Reserve members, their families, certain former spouses, and other eligible individuals. 

Simply put, it is a federal program that brings together civilian and military healthcare providers and resources to provide high-quality healthcare services. 

If you are interested in getting credentialed with Tricare, continue reading!

A Step-by-Step Guide to Tricare Credentialing Application

Tricare is managed in two stateside regions, i.e., Tricare East and Tricare West. Where you live determines your region. Confirm your region before proceeding forward because the process for both regions varies significantly.

The main reason is that Humana Military manages the Tricare East, while TriWest Healthcare Alliance (TriWest) handles the West region.

Tricare East Credentialing Application Process (Managed by Humana Military)

Here are the steps involved if you are credentialing for the Tricare East:

Step 1: Check Network Status

Your first step should be to check the network status for getting credentialed with Tricare in the East Region. 

Since Humana Military often has a closed network for certain specialties, this step will save you time and effort. Thus, verify if they are accepting new network providers in your area before applying.

Step 2: Obtain Tricare Certification 

Your next step should be to become a Tricare-authorized healthcare provider. This involves submitting a provider certification application via the Humana Military portal. It is an integral step that confirms you meet federal licensing standards.

Step 3: Credentialing & Contracting 

Note that once certified, you will become a non-network authorized provider only. That is, you must submit a request for a participation agreement to become an in-network provider.

Humana uses its own internal credentialing team. They will verify your Council for Affordable Quality Healthcare (CAQH) profile and malpractice history.

The Tricare East credentialing processing time ranges from 90 to 120 days.

Tricare West Credentialing Application Process (Managed by TriWest Healthcare Alliance)

Let’s review the steps involved in the Tricare credentialing application process in the West region:

Step 1: Complete the Credentialing Application

The first step should be to fill out the provider contract request on the TriWest website. It will act as your initial inquiry.

Step 2: CAQH Authorization 

Since TriWest relies heavily on the CAQH, you should strive to keep your CAQH profile up to date.

Besides, do not forget to grant ‘global’ or ‘TriWest’ access to your profile.

Step 3: Primary Source Verification

Once your application is submitted, TriWest’s credentialing review team will verify your professional credentials, board, education, and background. The national credentials verification organization, Aperture Credentialing LLC, assists in completing the verification.

Step 4: Contract Execution

Once your Tricare credentialing application status shows “Approved”, you will receive a fully executed contract. 

However, you are not an in-network provider until the document is signed by both parties. Besides, you should expect 90 to 120 days for full onboarding in the West region.

Tricare Provider Credentialing Requirements

The following are the core Tricare credentialing requirements:

• You must have a current, valid, and unrestricted license in the state where you practice. Besides, the license must allow for independent practice (with specific exceptions for certain mental health counselors).
• A Type 1 (Individual) National Provider Identifier (NPI) is required.
• Proof of graduation from an accredited medical, professional, or graduate school, including transcripts or diplomas.
• Board certifications are also a key requirement for Tricare authorization.
• A current, unrestricted Drug Enforcement Administration (DEA) and state-controlled substance certificate (if applicable to your specialty).
• Proof of professional liability insurance that meets the minimum coverage limits required by the specific Tricare regional contractor.
• You must have a clean background check. That is, you should not have any felony convictions or a history of disciplinary actions. Moreover, you cannot be on the Office of Inspector General (OIG) Exclusion list or the System for Award Management (SAM) debarment list.
• An updated CV with no unexplained gaps in employment exceeding six months.
• Tricare specifically requires Basic Life Support (BLS) or cardiopulmonary resuscitation (CPR) certification that includes a live/in-person component. Note that fully virtual courses are not accepted.

There are also a few region-specific requirements, which are listed below:

For Tricare East

You must submit a provider certification application to become a Tricare-authorized provider. Following it, you need to initiate an additional ‘join the network’ inquiry for successful credentialing with Tricare.

For Tricare West

In the West region, CAQH is the primary source for data collection. Thus, you must ensure an up-to-date CAQH profile.

Challenges in Getting Credentialed with Tricare

The following are some of the key challenges that healthcare providers encounter in their pursuit to get credentialed with this insurance payer:

• The entire process from credentialing to Tricare healthcare provider enrollment can stretch 90 to 120 days. This lengthy processing timeline can make it challenging for physicians to start seeing active service members, veterans, and others enrolled in the Tricare insurance plans.
• Physicians applying for the Tricare network may experience application rejection because of entirely online BLS/CPR certifications.
• Long hold times and a lack of status updates from regional contractor portals also make it difficult for providers to confirm their Tricare credentialing application status.
• Regional contractors frequently update credentialing standards. If the updates happen mid-application, it results in mismatched billing information and sudden application denials.
• For Tricare West credentialing, failure to grant specific ‘TriWest’ or global access to the CAQH portal is a leading cause of silent application stalls.
• Even after becoming a Tricare-authorized provider, a regional contractor can deny you the in-network status. The main cause of this application rejection is that the contractor may determine that the specific geographic area has sufficient providers in that specialty.

Best Practices for Tricare Insurance Credentialing

If you want to ensure successful credentialing with Tricare, implement the following best practices:

Prioritize Certification Over Networking

Do you want to become an in-network provider with Tricare in the East region? Then you must first be a Tricare-authorized provider. Skipping this essential step will result in immediate application rejection.

Audit CAQH Profiles Monthly

Are you from the West region and want to get credentialed with Tricare? If yes, do not forget to grant specific TriWest or global access on your CAQH profile. 

Moreover, you should re-attest your CAQH profile every 120 days. It is integral because even a single day’s lapse in attestation can freeze your application.

Verify Hands-On BLS/CPR Training 

Tricare has strict policies when it comes to BLS/CPR training. That is, it rejects 100% online BLS/CPR certifications. Thus, you must ensure that your certificates explicitly state that you completed a classroom or hands-on component.

Match Legal Names Exactly

Mismatch in the healthcare provider’s name on the credentialing application and professional credentials and state licenses can result in immediate rejection. Thus, ensure the name matches down to the middle initial or suffix (e.g., Jr., Mc., or A). 

Ensure Proactive Renewals 

The regional contractor’s systems may lag in updating expiration dates. Thus, you should start the re-credentialing process at least 120-150 days before a license or malpractice policy expires.

Explain Experience Gaps  

The provider’s CV should not have gaps longer than 30 days. If a gap exists, attach a signed explanation letter to the initial packet. It will help you prevent a Request for Information (RFI) and streamline the process.

Proactively Follow-Up On Application Status

You should focus on implementing a weekly Tricare credentialing application status check via the Humana Military (East) or TriWest (West) portals. 

Additionally, if your application has a pending status for more than 14 days without movement, call the regional contractor for updates.

Keep a Record of Every Interaction

Document every call to the regional contractor, including the representative’s name and the specific reference number for the call. This best practice will make it easier for you if you ever need to escalate a stalled application.

Collaborate with a Medical Credentialing Company

Entrusting your Tristar provider credentialing to a prominent medical credentialing company could really simplify and speed up the process. Why? These medical credentialing companies are known to hire skilled professionals who have years of experience helping physicians and other healthcare providers get credentialed and enrolled in renowned payer networks. It is their job, and they have done it right a hundred times.

Partner with MediBillMD to Streamline the Tricare Credentialing Process

To summarize, the Tricare credentialing process is lengthy and complex. Thus, whether you are applying to the West or East region, you must have a dedicated credentialing team by your side for successful and timely enrollment. 

Do you have a credentialing expert? If not, dump the worries and outsource insurance credentialing services to professionals at MediBillMD. Our comprehensive credentialing solutions include provider enrollment, clearinghouse enrollment, insurance credentialing, hospital credentialing, PECOS & CAQH credentialing, healthcare licensing, payer contract management, and re-credentialing.