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United Healthcare and TRICARE West Region Contract

Friday, December 21, 2012   (0 Comments)
Posted by: Lucas Centeno
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APTA members in the TRICARE West Region have expressed concerns and questions about the new contract between United Healthcare and TRICARE. Please feel free to forward this information to your members.

Background Information

•          UnitedHealthcare Military & Veterans has been awarded the Department of Defense contract to provide the TRICARE West Region with managed care support services

.•          UnitedHealthcare will replace the current TRICARE West Region contractor on April 1, 2013.•          UnitedHealthcare has contracted with OptumHealth to provide the physical therapy, occupational therapy, and speech-language pathology (PT/OT/SLP) network.

 •          TRICARE West Region includes 2.9 million eligible beneficiaries in 21 states.

•          All participating OptumHealth providers in the TRICARE West Region were sent a TRICARE amendment in September 2012.

•          Additional providers were sent TRICARE amendments in October 2012.

•          OptumHealth is following the provider specialties communication, timeline and policies required by the Department of Defense.



Frequently Asked Questions

1.    Why is it important to become a TRICARE provider?

TRICARE is the health care program for uniformed service members, retirees and their families. These Americans make sacrifices every day to keep our country safe and strong. Becoming a TRICARE provider means that you will have the opportunity to give back by treating America’s heroes, their spouses and children.


2.    When will I receive the Provider Administrative Manual?

UnitedHealthcare Military and Veterans is working with TRICARE to finalize the Manual. We expect to mail it by January 2013.


3.    What is CHAMPVA?

CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries. CHAMPVA is managed by the VA’s Health Administration Center (HAC) in Denver, Colorado.


 4.    Is there a contract or agreement that I must sign to participate in CHAMPVA?

No. CHAMPVA does not require providers to be contracted. You must be properly licensed in your state to receive payment from CHAMPVA and cannot be on the Medicare exclusion list.


5.    Do I have to participate with CHAMPVA to see TRICARE members?

In order to be eligible to become a participating provider with TRICARE, you must be willing to accept CHAMPVA members. Federal regulations state that providers must accept the CHAMPVA allowable rate and cannot balance bill the beneficiary.


6.    Since I am already a TRICARE Provider, why do I need to do anything?

The UnitedHealthcare Military and Veterans TRICARE West Region contract begins April 1, 2013. Current contracts do not transfer, so new agreements need to be established to prevent any disruption during the transition. To participate with TRICARE, you must be an OptumHealth contracted and credentialed provider. Our primary goal is to offer TRICARE beneficiaries continued access to care and services.


 7.    What do I need to do to continue treating TRICARE members?

Please complete and return the two documents listed below along with a current roster of providers within your group. 1) Provider Information Form2) Individual Therapist Credentialing Form8.   


8. What if I am not contracted and credentialed with OptumHealth?

Call OptumHealth provider services at 800-873-4575 to request a contracting packet for TRICARE. OptumHealth uses the Council for Affordable Quality Healthcare’s® (CAQH) Universal Provider DataSource® (UPD) web-based application for credentialing. The Individual Therapist Credentialing Form you submit is used to start your credentialing process and CAQH will mail you a provider ID to complete the online application process. Please complete the application process quickly and attach all required documents.


9.    How long does the credentialing process take?

Credentialing takes approximately 30-45 days after the completed application is submitted to CAQH. You will receive a letter notifying you of the OptumHealth Credentialing Committee decision.


10.  Is there a fee to become an OptumHealth provider?

No, there is no fee required to become an OptumHealth provider. 


11.  Why is there no fee schedule attached to the mailing?

Your fee schedule is based on a percent of the TRICARE maximum allowable rates, located on page 20 of your OptumHealth – TRICARE Amendment. The TRICARE maximum allowable rates can be viewed at


12.  Will I need to submit the OptumHealth Patient Summary Form (PSF) to be reimbursed?

No. There is no OptumHealth utilization management program requirement for TRICARE.


13.  Will durable medical equipment (DME) be reimbursed?

Yes, DME is currently covered under the TRICARE program when ordered by a licensed physician.  However, OptumHealth is verifying with TRICARE when PT/OT/ST providers can be reimbursed for DME. 


14.  As a TRICARE provider with OptumHealth, am I required to submit my claims electronically?

No. Initially, providers were informed that they must submit all claims electronically. However, more recently we were informed that providers will be able to submit paper claims for TRICARE members.


15.  Who is paying claims?

UnitedHealthcare has partnered with the same entity currently paying TRICARE claims in the North and South regions. The TRICARE claims processor is Palmetto Government Benefits Administrators (PGBA, LLC), a division of Blue Cross Blue Shield of South Carolina.


16.  What is the new Payor ID? 

The new Payor ID is 99726 and should be used for dates of service starting April 1, 2013 when submitting claims to UnitedHealthcare Military & Veterans.


17.  Do I need to change my Payor ID now?

No. Please wait until the transition date occurs in April, 2013 before any updates are made to your Payor ID.

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