Navigating the TRICARE West / TriWest Credentialing Journey

1) The Big Transition: Health Net → TriWest as of Jan 1, 2025

As of January 1, 2025, TriWest Healthcare Alliance assumed responsibility for claims, authorizations, referrals, and network contracting in the TRICARE West region
(sources: integralclinicsolutions.com, tricare.triwest.com).
This means that any credentialing or contracting that was in progress via the previous contractor (Health Net) may need to be revisited or restarted under the new regime (integralclinicsolutions.com).

2) Certification vs. Credentialing vs. Contracting — What’s the Difference?

• Certification / Authorization: TRICARE’s determination that a provider is qualified to render TRICARE-covered services and submit TRICARE claims.
• Credentialing: Verification of qualifications — licensure, education, board certification, malpractice history, background checks, etc.
• Contracting (Network Enrollment): Signing a network agreement with TriWest to join the TRICARE provider network (accepting assignment, agreeing to TRICARE reimbursement rules, etc.).

To be an active network provider under TRICARE West / TriWest, you typically need all three: certification (TRICARE authorization), credentialing, and a signed contract
(tricare.triwest.com). TriWest notes that credentialing approval is sent separately from the fully executed contract (tricare.triwest.com).

3) Steps in the Credentialing / Enrollment Process

Below is a generally sequential overview. In practice, some steps may overlap.

4) Minimum Credentialing Criteria & Disqualifying Factors

TriWest (under TRICARE) maintains baseline standards for providers (tricare.triwest.com). Highlights include:

Must-Have Criteria (Individual Providers)

• Education, training, and board certification (or equivalent) in your specialty
• Active, unrestricted license(s) in the state(s) of practice
• DEA or controlled substance registration (if applicable)
• Adequate malpractice / professional liability insurance (meeting state/TRICARE requirements)
• No felony convictions; not excluded from federal programs
• No gaps in professional work history > 6 months (unless explained)
• No prior license terminations for cause or voluntary relinquishment under threat of action
• Ability to practice independently (unless your role legally permits supervision)

Institutional / Facility Criteria

• Active and unrestricted facility license or accreditation
• Adequate liability insurance
• Compliance with accrediting bodies and regulatory agencies
• Not excluded from federal programs

Providers or facilities with exclusions, sanctions, unresolved complaints, or quality-of-care concerns may be denied credentialing (tricare.triwest.com).

5) Common Challenges, Pitfalls, and Delays 2025 Edition

a) Unresponsiveness & Missing Feedback

Many providers report sending packets to credentialing@triwest.com with no reply (even for missing items) and long waits without follow-up
(Reddit).

Tip: Follow up persistently via multiple channels (email + phone). Keep detailed records of submissions and contacts.

b) System / Data Migration Errors

During the transition from Health Net to TriWest, some records were reportedly lost, duplicated, or misaligned, causing previously credentialed providers to appear “not credentialed”
(Reddit).

Tip: If you were credentialed under Health Net, include proof of prior credentialing (effective dates, letters, contracts) to aid reconciliation.

c) Disputes Over Claims & Network Status

Some providers listed as in-network report claims processed out-of-network or denied for authorizations (Reddit).

Tip: After credentialing, confirm your active status across all systems (directories, claims, referrals). Reference credentialing effective dates on claims when needed.

d) Authorization / Referral Confusion

TRICARE Prime in the West generally requires PCM referrals/authorizations. Due to system issues, DHA instituted a waiver for outpatient specialty referrals through certain dates (e.g., through June 30, 2025) to avoid penalizing patients
(TRICARE Newsroom).

Tip: Check current TRICARE / TriWest policy or provider portals. If a waiver is active, ensure adjudication reflects it and that PCMs are submitting correctly.

e) Delays in Payment & Backlog

Reports note significant payment delays, incomplete payments, or checks with missing EOBs
(aota.org; Reddit).

Tip: Keep tight AR workflows and escalate unpaid claims when necessary. Consider phasing in TRICARE volume until payment cycles stabilize.

6) Best Practices & Strategies to Accelerate Success

• Submit a complete application: Missing or inconsistent documents are the #1 cause of delay.
• Use CAQH (if available): Ensure your CAQH profile is current (tricare.triwest.com).
• Track & document everything: Keep email logs, dates, contact names, and form versions.
• Follow up proactively: After submitting, check in periodically (e.g., every few weeks) for status updates.
• Engage local contacts / peers: Identify liaisons or champions who can help escalate issues.
• Prepare for recredentialing hurdles: Keep licensure, insurance, and records up to date ahead of the 3-year renewal.
• Budget for delays: Plan for slower cash flow during the initial on-ramp.
• Leverage professional associations: Groups like AOTA have been advocating for provider support (aota.org).

7) Sample Timeline & Expectations (Ideal vs. Real-World)

* Ideal durations assume a fully complete, clean application without additional issues.

Given the transitional state in 2025, some providers suggest the process can feel effectively “on hold” while TriWest resolves migration and backlog challenges (Reddit).

8) What to Do Right Now (If You’re a Prospective TRICARE West Provider)

1. Check whether your locale is open for new providers.
2. Gather all documentation in advance, including prior TRICARE contracts or credentialing letters.
3. Submit clean, thoroughly reviewed application packets to the correct TriWest email(s) (e.g., credentialing@triwest.com, provcerts@triwest.com) depending on provider type (tricare.triwest.com).
4. Follow up persistently — don’t let your application sit unmonitored.
5. Request status updates in writing to maintain a paper trail.
6. Monitor claims; if paid out-of-network or denied, raise the issue immediately.
7. Network with providers in your state who have completed (or are in) the process for local tips.
8. Stay current on policy updates — referral/authorization and claims rules may shift.

9) Conclusion & Outlook

The TRICARE West credentialing and contracting process under TriWest is absolutely doable — but in 2025, go in with eyes wide open. The system transition, backlog, communication issues, and data migration challenges make this more complex than in past years.

If you are entering the process now, budget extra time, stay organized, document every step, and follow up frequently. With patience and persistence, you can become an active TRICARE West provider and open your doors to military beneficiaries in your region.