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TRICARE for Behavioral Health Providers

Guide to TRICARE credentialing, prior authorization, VOB, and billing for behavioral health facilities serving military beneficiaries in East and West regions.

TRICARE

TRICARE (Department of Defense Military Health System)

TRICARE behavioral health provider guide — military/DHA regional contractors, Prime and Select plans, credentialing, authorization, and claims.

Quick Reference

Payer Type
Government
Parent Company
US Department of Defense — Defense Health Agency (DHA)
Headquarters
Falls Church, VA
Provider Portal
Open Portal
Portal Guide
View Guide →
Credentialing
Regional network contractor (Humana Military for East; TriWest Healthcare Alliance for West); most use CAQH ProView
Timeline
Typically 60-120 days (varies by regional contractor)
Coverage
1 states
Last Verified
Apr 19, 2026
Published
Apr 19, 2026
Reading Time
8 min

Covered Levels of Care

  • Medically Managed Detoxification
  • Residential Treatment (adults and adolescents)
  • Partial Hospitalization Program (PHP)
  • Intensive Outpatient Program (IOP)
  • Outpatient Treatment
  • Medication-Assisted Treatment (MAT)
  • Opioid Treatment Program (OTP) services

Medical Necessity Criteria

  • ASAM Criteria (for substance use disorders)
  • TRICARE Policy Manual clinical criteria

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Overview

TRICARE is the health care program of the United States Department of Defense Military Health System, providing medical and behavioral health coverage to approximately 9.6 million beneficiaries as of 2025, including active duty service members, members of the National Guard and Reserve, retirees, their families, survivors, and certain former spouses. The program is administered by the Defense Health Agency (DHA) ↗, a joint combat support agency headquartered in Falls Church, Virginia, that took over the program from the individual military services in 2013.

Unlike commercial payers, TRICARE is not a single insurance company. DHA sets benefits, policies, and provider network standards at the federal level, and contracts with private managed care support contractors to operate regional networks, credential providers, process claims, and perform utilization management. The contractors currently are Humana Military ↗ for the TRICARE East Region and TriWest Healthcare Alliance ↗ for the TRICARE West Region. Contractor awards rotate on multi-year cycles; verify the current contractor at tricare.mil/Providers ↗ before investing significant credentialing effort.

Beneficiaries enroll in one of several plan options: TRICARE Prime (a managed care plan with primary care manager gatekeeping, similar to an HMO), TRICARE Select (a preferred provider option similar to a PPO), TRICARE For Life (a Medicare wrap for Medicare-eligible beneficiaries), TRICARE Reserve Select (for Selected Reserve members not on active orders), TRICARE Retired Reserve, and TRICARE Young Adult for qualifying dependents through age 25. Plan rules drive cost-shares, referral requirements, and how tightly the network gate is enforced.

Behavioral Health Coverage

TRICARE covers a broad continuum of mental health and substance use disorder (SUD) services, with benefits grounded in the TRICARE Policy Manual (TPM) and TRICARE Reimbursement Manual (TRM) published by DHA at manuals.health.mil ↗. Covered levels of care include medically managed and medically monitored detoxification, residential SUD and psychiatric treatment for adults and adolescents, partial hospitalization programs, intensive outpatient programs, standard outpatient therapy, psychiatric evaluation and medication management, and medication-assisted treatment including full coverage of FDA-approved medications and opioid treatment program services.

SUD coverage is notably robust compared to many commercial plans. Active duty service members receive services without cost-share when properly referred, and dependents generally face modest cost-shares under Prime or Select. The program covers methadone, buprenorphine products, and injectable naltrexone along with the counseling services bundled into opioid treatment program bundled rates. Behavioral health care for combat-related conditions — post-traumatic stress disorder, traumatic brain injury sequelae, military sexual trauma — is a priority focus area, and DHA publishes clinical practice guidelines for these conditions.

Medical necessity for SUD services is evaluated against ASAM Criteria; mental health services are evaluated against TRICARE Policy Manual criteria and, for some conditions, Department of Defense / Department of Veterans Affairs clinical practice guidelines ( healthquality.va.gov ↗ ). Residential and inpatient stays are subject to maximum benefit periods defined in the TPM, though clinical exceptions are available when warranted.

Credentialing and Provider Enrollment

Credentialing for TRICARE is performed by the applicable regional contractor rather than DHA. Facilities and clinicians that want to participate in the TRICARE network must apply to Humana Military (East), TriWest Healthcare Alliance (West), or both if they operate across regions. There is no single national TRICARE credentialing pathway.

Both contractors use CAQH ProView as the primary data source for individual clinician credentialing. Facility-level documentation is collected separately and typically includes the current state behavioral health facility license, accreditation certificates (Joint Commission, CARF, or COA depending on level of care), professional and general liability insurance meeting the contractor’s minimums, an organizational NPI, Tax ID and W-9, ownership and control disclosure, DEA registrations for prescribing staff, state controlled substance registrations where applicable, OTP SAMHSA certification and DEA OTP registration if applying for opioid treatment program services, and a facility program description describing staffing and services for each level of care. Credentialing typically runs approximately 60 to 120 days from submission of a complete application.

Providers may also deliver care to TRICARE beneficiaries on a non-network basis. Non-network participating providers accept the TRICARE allowable charge as payment in full; non-participating providers may balance-bill up to a statutory limit. Active duty service members must use network providers absent authorization; other beneficiaries in Select plans may use either network or non-network providers but pay higher cost-shares out of network.

Recredentialing generally occurs every three years. Keep your CAQH ProView attestation current and notify the contractor of any material changes to licensure, accreditation, or ownership within the contractor’s notification window.

Verification of Benefits (VOB)

Eligibility for TRICARE flows from the Defense Enrollment Eligibility Reporting System (DEERS). Providers should verify eligibility for each beneficiary through the applicable regional contractor’s provider portal, by calling the beneficiary services number on the back of the uniformed services ID card, or via standard HIPAA 270/271 electronic transactions through your clearinghouse.

When verifying benefits for a behavioral health admission, confirm: active enrollment and the specific plan (Prime, Select, For Life, Reserve Select, etc.); whether a referral or authorization is required for the proposed level of care; the beneficiary’s cost-share category and deductible status; any annual or per-admission day limits; whether the beneficiary is active duty and therefore requires coordination with the Service Point of Contact or military treatment facility; and whether other health insurance is in place (TRICARE is generally secondary to most other coverage). Document the verification date, reference number, and representative name.

Beneficiaries and providers can also access eligibility and plan information via the DoD’s milConnect portal using a Common Access Card (CAC) or DS Logon. For TRICARE For Life beneficiaries, primary eligibility information lives with Medicare; TRICARE For Life receives claim data after Medicare adjudicates.

Prior Authorization Requirements

TRICARE generally requires prior authorization for inpatient psychiatric care, residential SUD and mental health treatment, partial hospitalization programs, and certain intensive outpatient arrangements. Outpatient therapy is generally not subject to prior authorization, though some services — such as applied behavior analysis, psychological testing beyond a threshold, or certain out-of-network care — may have authorization or referral requirements depending on plan.

Prior authorization requests are submitted to the regional contractor. Humana Military processes East Region requests through its provider portal and clinical lines; TriWest processes West Region requests through its provider portal. Submissions should include a clinical assessment, DSM-5 diagnoses, an ASAM multi-dimensional assessment for SUD requests, a treatment plan with measurable objectives, and a rationale for the requested level of care.

Active duty service members have an additional layer — care for active duty beneficiaries usually requires involvement of a Service Point of Contact, and for some conditions, coordination with the military treatment facility commander. Reservists on active duty orders are treated similarly.

Concurrent review is standard for residential, inpatient, and PHP stays. Frequencies vary by contractor but commonly run every 5 to 10 days for residential. Denials are subject to the TRICARE appeals process, which includes reconsideration by the contractor, review by a DHA hearing officer, and ultimately federal court review for final agency decisions.

Claims and Billing

TRICARE claims submit to the regional contractor rather than directly to DHA. Electronic claims use standard EDI 837I (institutional, UB-04 based) and 837P (professional, CMS-1500 based) formats, routed to Humana Military’s payer ID for East Region beneficiaries or TriWest’s payer ID for West Region beneficiaries. Confirm the current payer IDs with your clearinghouse before submitting volume.

TRICARE For Life claims for dual-eligible beneficiaries (those with Medicare Part A and Part B) process through Medicare first, with the crossover claim flowing to TRICARE as the secondary payer. Most Medicare Administrative Contractors have automated crossover arrangements with the TRICARE For Life claims processor, but providers should monitor the crossover in their remittance advice to ensure the TRICARE portion is paid.

The TRICARE timely filing limit is generally one year from the date of service or discharge, which is more generous than most commercial payers, though specific terms can vary. Timely filing exceptions may apply for good cause such as delayed eligibility determinations. Common denial reasons include missing prior authorization, services exceeding the benefit day limit, non-covered services under the TPM, coordination-of-benefits issues when other insurance was not billed, and coding errors.

Appeals follow a structured multi-level process defined in 32 CFR Part 199. The first level is reconsideration by the regional contractor; subsequent levels involve DHA. Filing deadlines and procedures are specified in the original determination letter — observe them carefully because TRICARE appeal rights are time-barred.

Key Contact Information

  • Program Home: tricare.mil ↗ — beneficiary and provider portal for TRICARE
  • Provider Resources: tricare.mil/Providers ↗
  • TRICARE Policy Manual and Reimbursement Manual: manuals.health.mil ↗
  • TRICARE East Region (Humana Military): humanamilitary.com/provider ↗
  • TRICARE West Region (TriWest Healthcare Alliance): tricare.triwest.com/en/provider ↗
  • Defense Health Agency: health.mil ↗
  • DEERS / milConnect (eligibility): milconnect.dmdc.osd.mil ↗
  • TRICARE For Life: Administered separately; see tricare.mil/tfl ↗ and coordinate with Medicare as primary payer
  • Appeals regulation: 32 CFR Part 199 (published on ecfr.gov ↗ )

Frequently Asked Questions

TRICARE currently contracts with two regional managed-care support contractors. [Humana Military](https://www.humanamilitary.com/provider) administers the TRICARE East Region, which covers most states east of the Mississippi plus Arkansas, Illinois, Louisiana, Oklahoma, Texas, Wisconsin, and parts of Iowa, Minnesota, and Missouri. [TriWest Healthcare Alliance](https://tricare.triwest.com/en/provider/) administers the TRICARE West Region, covering the remaining western states. Contract holders rotate on multi-year cycles, so always verify the current contractor at [tricare.mil/Providers](https://www.tricare.mil/Providers) before submitting claims or credentialing applications.

TRICARE covers a full continuum of SUD services for active duty service members, retirees, and eligible dependents, including medically managed and medically monitored detoxification, residential substance use disorder treatment, partial hospitalization, intensive outpatient, outpatient individual and group therapy, and medication-assisted treatment including opioid treatment programs. Coverage details and cost-shares vary by plan (Prime, Select, For Life, Reserve Select, Young Adult) and by beneficiary category. Active duty service members generally have the most generous coverage with no cost-share. Current covered services and criteria are described in the TRICARE Policy Manual at [manuals.health.mil](https://manuals.health.mil).

Credentialing is handled by the regional contractor rather than DHA directly. In the East Region, facilities contract with [Humana Military](https://www.humanamilitary.com/provider); in the West Region, with [TriWest Healthcare Alliance](https://tricare.triwest.com/en/provider/). Most contractors use CAQH ProView as the primary credentialing data source for clinicians and collect facility-level documentation separately, including state license, accreditation (Joint Commission, CARF, or COA depending on level of care), professional liability coverage, NPI, W-9, ownership disclosure, and in many cases a facility program description. Typical credentialing timelines run approximately 60 to 120 days. If you operate across both regions, you must credential with both contractors.

Yes. TRICARE generally requires prior authorization for inpatient psychiatric care, residential SUD and mental health treatment, partial hospitalization, and in many cases intensive outpatient. Requests are submitted to the applicable regional contractor (Humana Military or TriWest) and reviewed against the TRICARE Policy Manual and, for SUD, the ASAM Criteria. Active duty service members have additional referral requirements through their military treatment facility or Service Point of Contact. Emergency admissions generally require notification within 24 to 72 hours depending on the contractor and plan. Always verify current requirements before admission by calling the number on the back of the beneficiary's uniformed services ID or using the contractor's provider portal.

Claims submit electronically through your clearinghouse to the applicable regional contractor's payer ID — Humana Military for East Region beneficiaries and TriWest Healthcare Alliance for West Region beneficiaries. Use UB-04/837I for institutional and CMS-1500/837P for professional. The TRICARE timely filing limit is generally one year from the date of service, though specific deadlines can vary by plan and circumstance. TRICARE For Life claims for dual-eligible Medicare beneficiaries process first through Medicare, then cross over to TRICARE as the secondary payer. Verify current payer IDs and mailing addresses at [tricare.mil/Providers](https://www.tricare.mil/Providers).

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This guide is provided for informational purposes only and does not constitute legal, regulatory, or professional advice. Payer requirements, phone numbers, and portal URLs are subject to change. Always verify current information directly with the payer. is not affiliated with the insurance companies described on this page.

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1,894 words · reviewed 2026-04-19
TRICARE for Behavioral Health Providers — The Behavioral Health Resource Solution