CurrentBlue Cross Blue Shield - NebraskaPolicy N/A

TRICARE West Region Referral Waiver for Outpatient Services

This document approves a temporary waiver permitting TRICARE Prime beneficiaries in the West Region to receive certain outpatient TRICARE-covered services without separate TriWest prior-authorization when referred by an authorized provider; it affects TRICARE Prime patients and their providers.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyTRICARE West Region Referral Waiver for Outpatient Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionReferrals issued Jan 1–Jun 30, 2025 by a PCM or other TRICARE-authorized provider do not require separate TriWest approval for eligible outpatient services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1–Jun 30, 2025referral issuance window

Sep 30, 2025service render through

Outpatientincluded service type

TriWest not requiredprior auth waived

Waiver Eligibility and Limitations

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyTRICARE West Region Referral Waiver for Outpatient Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionReferrals issued Jan 1–Jun 30, 2025 by a PCM or other TRICARE-authorized provider do not require separate TriWest approval for eligible outpatient services.

SourceLink

On This Page

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ALL of the following

ALL of the following
- TRICARE Prime in West Regioneffective Jan 1, 2025 through Jun 30, 2025
  Applies to TRICARE Prime beneficiaries
ALL of the following
- Referral must be issued by
  - Military primary care manager (PCM)
  - Civilian primary care manager (PCM)
  - Other TRICARE-authorized provider
    TRICARE-authorized providers include network and non-network providers (see TRICARE provider directories)
ALL of the following
- Referral issue date2025-01-01 to 2025-06-30
  Referrals issued between Jan 1 and Jun 30, 2025 are covered by the waiver
- Service render dateon or before 2025-09-30
  Services initiated or rendered through Sep 30, 2025 are included

ALL of the following

Included services
- TRICARE-covered office visits, outpatient procedures, services, and equipment that otherwise require TriWest approval when ordered/initiated during the waiver period
Exclusions (NOT covered by waiver)
- Inpatient care
- Applied behavior analysis (ABA)
- Autism Care Demonstration (ACD) services
- Other services that require pre-authorization as listed on Availity

ALL of the following

Claims documentation
A copy of the TRICARE West Region Referral Waiver Approval Letter is not required with claim submission
After waiver ends
Referrals and orders issued after Jun 30, 2025 must follow TRICARE referral and authorization requirements; point-of-service charges and authorization penalties may apply if TriWest approval is not obtained

Coding and Coverage Period

No specific billing or procedure codes providedmixed

No codes listed

Waiver coverage period

Waiver referral issuance windowReferrals issued January 1, 2025 through June 30, 2025

Service render deadlineServices authorized by those referrals may be rendered through September 30, 2025

Scope of covered services during periodTRICARE-covered office visits, outpatient procedures, services, and equipment that otherwise require TriWest approval when referred by an authorized provider

ExclusionsInpatient care, applied behavior analysis (ABA), Autism Care Demonstration (ACD) services, and other services that require pre-authorization

Claims documentationA copy of the waiver approval letter is not required with claim submission

Provider Responsibilities and Authorization Rules

Prior Authorization

Waiver of TriWest prior authorization for eligible outpatient referrals

During the TRICARE West Region outpatient referral waiver period (Jan 1, 2025–Jun 30, 2025), eligible outpatient referrals and orders issued by a military or civilian primary care manager (PCM) or other TRICARE-authorized provider do not require separate prior authorization from TriWest for services that would otherwise need TriWest approval. This waiver applies to TRICARE-covered office visits, outpatient procedures, services, and equipment when the referral or order was issued between January 1, 2025 and June 30, 2025. Beneficiaries are encouraged to bring the PCM referral to their specialty appointment.

Effective dates: Referrals/orders issued Jan 1, 2025 through Jun 30, 2025 are valid for services rendered through Sep 30, 2025.
Scope: Applies to TRICARE-covered outpatient services that otherwise require TriWest approval when referred by a PCM or other TRICARE-authorized provider.
Exclusions: Inpatient care, Applied Behavior Analysis (ABA)/Autism Care Demonstration (ACD) services, and other services that explicitly require pre-authorization remain excluded from the waiver.

Denial Risk

Post-waiver authorization requirement and penalties

When the waiver period ends, referrals and orders issued after June 30, 2025 must follow standard TRICARE referral and authorization requirements. Providers who submit services without obtaining required TriWest approval after the waiver ends may face point-of-service charges assessed to the beneficiary and other authorization-related penalties. Ensure authorizations are obtained from TriWest for any services that fall outside the waiver window or for services expressly excluded from the waiver.

Referrals/orders dated after Jun 30, 2025 require TriWest approval.
Penalties: Point-of-service charges and authorization penalties may apply if TriWest approval is not obtained post-waiver.

Documentation Required

Claims documentation guidance

For claims submitted for services delivered under the waiver, a copy of the TRICARE West Region Referral Waiver Approval Letter is not required with the claim. Providers should, however, maintain appropriate documentation in the patient record showing the PCM or TRICARE-authorized provider referral/order and the date it was issued in case of retrospective review. Use Availity in the TRICARE West payer space (Applications) to verify whether specific services require pre-authorization outside the waiver.

Do not attach the waiver approval letter to claims — it is not required.
Retain documentation: Keep the referral/order and issuance date in the medical record to support claims if audited.
Verify pre-authorization requirements for specific services via Availity (TRICARE West payer space, Applications).

OpenPayer

TRICARE West Region Referral Waiver for Outpatient Services

Waiver Eligibility and Limitations

Coding and Coverage Period

Provider Responsibilities and Authorization Rules

Key Definitions