Understand the key changes to Tricare's administrative contractors, including the transition of six states to the West region and the shift in claims processors.
The Tricare contractor changes are just around the corner. Tricare's administrative contractors are divided between the East and West regions of the country. Due to new contracts, there are changes to both regions, effective January 1, 2025. Please refer to the resources listed at the bottom for more information from Tricare. Quadax has been preparing for these changes over the last two months, and below is a list of the changes and their impact on reimbursement-related electronic transactions: eligibility, claims, and remittances.
Six states from the East region will migrate to the West region: Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin. Claims with a date of service in 2025 must be submitted to the new West Regional Contractor, TriWest Healthcare Alliance.
It was announced on December 3, 2024, that there are four small "carve-out" areas in Arkansas, Indiana, Missouri, and Wisconsin that will not follow the states' 2025 regional assignment. The carve-out areas, identified by ZIP code, are in a border state or near a military hospital or clinic, and will be managed by the Regional Contractor of the region where the Prime Service Area (PSA) is located. 
Assignment of the correct insurance plan code is critical for proper claims processing. Changes to Standard Operating Procedures and the billing interface cross-reference tables may be needed to accommodate the change.
Eligibility: If a patient's insurance presents as East for a West-migrating state, the eligibility response from East will represent the payer as West, and the patient's insurance will need to be updated to West. Should Quadax's eligibility verification service be paired with Insurance Plan Select, the service will automatically derive the insurance plan code from the eligibility response, updating the patient's insurance accordingly.
Claims & Remittances: If the provider is not currently submitting claims to West (only operating in a state(s) that is currently in East), registration is needed with West for claims and remittances. Configuration changes are also required to ensure West is an active insurance for billing.
The Tricare West contractor is changing from Health Net Federal Services, LLC to TriWest Healthcare Alliance Corporation. The payer ID is staying the same (99726) because the claims processor is staying as PGBA. Health Net Federal Services will continue to process claims with 2024 dates of service through April 30, 2025.
Tricare East (Humana Military) will change their claims processor from Wisconsin Physicians Service (WPS) to PGBA. Claims with a date of service of 2025 must be submitted to PGBA, and claims with a date of service of 2024 can be submitted to WPS until April 30, 2025.
Claims: Quadax is already a direct submitter to PGBA, and no registration is needed. There is a new payer ID (99727) for 2025. Quadax will update the Tricare East insurance codes to the new payer ID on January 1, 2025. For claims with 2024 dates of service sent after January 1, 2025, an EDI XpressBiller rule will direct the claims to the WPS payer ID until April 30, 2025.
Remittances: Provider ERA and EFT enrollment is required if not already enrolled with PGBA. The Quadax insurance support team has been actively performing ERA registrations on behalf of our clients.
Consult with a Quadax Account Executive to learn more about these changes and discuss how the changes will impact your reimbursement operations.
Resources:
TRICARE Newsroom: TRICARE Regions Are Changing Jan. 1, 2025
Providers moving to the West Region (FAQs)
Providers staying in the East Region (FAQs)
