Thank you for being a part of TriWest Healthcare Alliance’s (TriWest) network and participating in TRICARE. Your care and support of our nation’s military and their families remains vital to our nation, especially in treating the hidden wounds of war. We understand the challenges in treating these conditions and are very appreciative of all that you are doing to care for them.
We are reaching out to you today to give you advance notice of an upcoming change in how we will handle certain inpatient mental health and substance use disorder (SUD) requests. TRICARE requires prior authorization for all nonemergent mental health and SUD inpatient admissions, as well as for intensive outpatient treatment and partial hospitalization programs. The only inpatient services that are allowed without an approved prior authorization are emergent acute hospital psychiatric admissions and acute SUD detoxification admissions. Those facilities are to notify TriWest of the emergent admission and request a concurrent review by the next business day after admission and no later than 72 hours after admission.
While most nonemergent facilities consistently obtain prior authorization and notify TriWest of admission, there are still a handful of cases each week that do not.
Effective May 15, 2026, TriWest will implement the following requirements for all nonemergent mental health admissions, including nonemergent acute psychiatric hospital admissions, psychiatric residential treatment center admissions, psychiatric residential treatment center admissions for children, and inpatient/residential SUD detoxification and rehabilitation care:
- If the mental health service requires prior authorization and the provider did not request it from TriWest, we will only authorize the days of care beginning with the date the provider notifies us. All days from the date of admission until the date TriWest was notified will remain unauthorized. Those days will require a retrospective review upon claims filing. If deemed medically necessary, the entire episode of care will be paid but with a penalty.
- If the mental health service had prior authorization but the provider did not notify TriWest of the admission, we will only authorize the days of care beginning with the date of admission notification. All days from date of admission until date of notification of TriWest will remain unauthorized. Those days will require a retrospective review upon claims filing and, if deemed medically necessary, will be paid but with a penalty. The penalty will be 10% as set forth in the TRICARE Reimbursement Manual, Chapter 1, Section 28, and the patient may not be billed for the amount of the penalty.
These actions align with the TRICARE Manuals. More information about a reduction of payment for noncompliance with utilization review requirements can be found in the TRICARE Reimbursement Manual, Chapter 1, Section 28.
Please note that prior authorizations can only be approved by the TRICARE managed care support contractor. Military treatment facility leaders and military commanders do not have the authority to approve prior authorization in lieu of TriWest. When a prior authorization is approved, TriWest sends a letter stating such to the requesting provider, the servicing provider, and the beneficiary. This letter and its associated entry in the provider and beneficiary portals serve as the source of verification of the prior authorization approval.
Thank you to those of you who are already following these steps properly. This notice has been sent to make all of our healthcare partners aware before making this change and ask for your help in ensuring compliance. If you have questions about or need support with a specific mental health authorization, contact TriWest’s Mental Health Utilization Management team at: T-5UMMentalHealthTeam@triwest.com.
Again, thank you for all that you are doing to care for this deserving population. We greatly appreciate your consideration in attending to the matters above. If you have any specific questions or concerns, please do not hesitate to reach out to TriWest Mental Health Medical Director Dr. Chris Warner at cwarner@triwest.com or 480-973-0806.
