TRICARE participation for PT, OT and SLP practices

For OT, PT and SLP practices treating children and adults in military families, including retirees: TRICARE pays only TRICARE-authorized providers, so each therapist is certified through the regional contractor first. Joining the network is a separate contract, and a non-network practice chooses claim by claim whether to accept the allowable charge as payment in full.⁠¹

What does TRICARE participation mean for a therapy practice?

It means three separate things, and a practice should know which of them it has for each therapist. Certification makes a therapist a TRICARE-authorized provider whose claims can be paid: the Defense Health Agency (DHA) states that every TRICARE provider must be authorized or certified under the TRICARE regulation and have that status verified by the regional contractor in each region.⁠^1,6 A network contract is an agreement with that contractor to see TRICARE patients at a negotiated rate. Participation, in TRICARE’s sense, is a choice a non-network provider makes on each claim: to accept the allowable charge as the full charge for the service.⁠^1,11

Certification is not coverage. The regulation says that a provider type’s listing does not mean TRICARE automatically pays its claims: the patient must be eligible, and the services authorized and medically necessary, whatever the provider’s standing.⁠¹² Nor is certification credentialing: Humana Military, the East Region contractor, requires credentialing only of the network providers it contracts with.⁠⁶ The credentialing guide draws the same lines for Medicare, Medicaid and commercial plans.

Which TRICARE contractor covers your therapy practice’s region?

The contractor for the region where you practice, and there are three regions. TRICARE is managed in the East, West and Overseas Regions, each with its own regional contractor, and other contractors support TRICARE For Life, the Uniformed Services Family Health Plan and the TRICARE Prime Demo.⁠¹³ On October 24, 2026, DHA’s provider page listed Humana Military for the East Region, TriWest Healthcare Alliance for the West Region and International SOS overseas, and TRICARE’s referral page named WPS Government Services as the TRICARE For Life contractor in the U.S. and U.S. territories.⁠^1,14 Read those two pages again before you file anything, and note the date you read them.

The regional contractor is the office that answers a therapist’s questions. DHA states that the regional contractors establish the provider networks and conduct provider education, and it tells providers who want to become TRICARE-authorized to call their regional contractor or visit its website.⁠¹

What if your practice treats patients in more than one state?

Each therapist needs authorization in every state where they treat TRICARE patients. The regulation requires a current license at full clinical practice level in each state where the individual treats TRICARE beneficiaries, and Humana Military states that practitioners must meet certification requirements in each practicing state.⁠^2,6 Humana Military also requires recertification when a provider starts practicing in a new state.⁠⁶ A practice whose locations sit in two regions has its status verified by the contractor in each.⁠¹

Can OTs, PTs and SLPs become TRICARE-authorized providers?

Yes. The regulation lists licensed physical therapists, occupational therapists and speech therapists (speech pathologists) among TRICARE’s individual paramedical providers, with referral conditions that differ by discipline.⁠² Each therapist must hold a current license at full clinical practice level in each state of practice; where a state does not license a profession, certification by a qualified accreditation organization takes its place, and TriWest’s therapist application asks speech pathologists in that position for a certificate of membership in the American Speech-Language-Hearing Association.⁠^2,15 Services must also fall within the scope of the license under the state’s practice act.⁠²

The referral is more than a signature. Where physician referral and supervision is a condition of payment, the regulation says the physician must actually see the patient to evaluate and diagnose the condition before referring, and must oversee the treatment that follows; written documentation of the reason for the referral and of ongoing communication between the referring and treating providers belongs in the medical record, though the physician need not be on site.⁠² Send progress reports to the referring clinician at the intervals your plan of care sets, and file what comes back with the chart. The guides to pediatrician referrals and adult therapy referrals cover building those relationships.

Do PTAs and OTAs need their own TRICARE certification?

The answer depends on the region, so ask before scheduling them with TRICARE patients. The regulation includes licensed or certified PTAs and OTAs who work under the supervision of a TRICARE-authorized PT or OT and meet Medicare’s qualifications; it names no speech-language pathology assistant.⁠² Humana Military says PTAs and OTAs do not complete certification because only their supervisors are eligible for reimbursement, while TriWest publishes a separate PTA and OTA provider application.⁠^6,16

Does Medicare enrollment make a therapist TRICARE-authorized?

The regulation points that way, but the contractors still verify each provider. It treats a practitioner who is eligible for Medicare reimbursement as approved for TRICARE unless there is information about program integrity violations, and limits that approval to the provider classes TRICARE already authorizes.⁠² DHA and Humana Military both state that every TRICARE provider must have certified status verified by the regional contractor, so file the certification application either way.⁠^1,17

How do you get a therapist certified for TRICARE?

File the regional contractor’s certification application for each therapist, attach what it lists, and keep the confirmation. Humana Military states that providers must be TRICARE-certified to file claims and receive payment, that practitioner applications, including those for physical therapists, occupational therapists and licensed registered speech pathologists, are submitted online, and that a copy of the license is always required.⁠^6,17 Its application for providers who see patients only by virtual health is faxed or mailed, and TRICARE applies the same referral requirements to virtual visits as to in-person care.⁠^17,18 Humana Military’s online applications can be followed in its certification status tracker.⁠⁶

TriWest’s non-network application for physical therapists, speech therapists, occupational therapists and audiologists asks for the license number with its original issue and expiration dates, solo or group practice details with the tax ID and NPI, and notarized signature authorization forms if someone other than the therapist signs claims; a PT or OT who offers hippotherapy attaches a certificate from the American Hippotherapy Certification Board.⁠¹⁵ It requires a separate application for each NPI, because the NPI billed on the claim decides where payment and remittance go, and it expects claims to be submitted electronically.⁠¹⁵

Should your therapy practice join the TRICARE network?

Join if the contractor is accepting requests for your services and the negotiated rate works for your practice; otherwise, a certified non-network practice can still treat Select, Reserve Select and TRICARE For Life patients.⁠⁶ A network provider signs a contract with the regional contractor, agrees to a negotiated rate, accepts the patient’s copayment or cost-share as payment in full and files the claims, and DHA notes that network providers are placed on the worldwide referral list for TRICARE beneficiaries.⁠¹ TRICARE describes negotiated rates as agreements with providers to accept less than the allowable charge.⁠³ The rate negotiation guide covers reading a rate exhibit before you sign.

Networks are not always open. On October 24, 2026, Humana Military’s certification page said it was not currently accepting requests to join the medical, surgical or ancillary networks in the East Region, while taking requests from providers certified for autism, psychiatry, mental health, substance abuse, doula or lactation services.⁠¹⁷ TriWest’s page asked West Region providers to fill out a Provider Contract Request form with their federal tax ID, after which a provider relations representative makes contact.⁠¹⁹

Participation can change from claim to claim. DHA states that non-network providers can choose to participate claim by claim and need not be participating or non-participating all of the time.⁠¹ The regulation requires institutional providers to participate on every claim and lets individual providers who have no participation agreement elect it claim by claim.⁠¹² Decide a default for the practice, write it into the billing procedure, and tell the patient before the visit which way the claim goes.

Network status also changes what you may ask of patients. TRICARE tells beneficiaries that network providers cannot ask them to sign a document agreeing to pay for authorized services, or for any part of a service TRICARE does not cover, and cannot refuse to see them for declining to sign one.⁠¹⁴ TriWest adds that a network provider must not require payment for excluded or excludable services, with a few exceptions, and that a general agreement to pay signed at admission is not evidence the patient knew a specific service was excluded.⁠²¹ Read your contract’s terms on non-covered services before you sign it.

What does TRICARE cover for PT, OT and speech therapy?

Medically necessary, proven therapy that meets each discipline’s conditions, with exclusions that differ by discipline. TRICARE’s covered-service pages say it covers services that are medically necessary and considered proven, and that their lists are not all-inclusive.⁠²²

Ask the contractor about limits rather than assuming one. TRICARE’s physical therapy page sends beneficiaries to their regional contractor for specific limitations to the benefit, so record what the contractor says for each patient’s plan and the reference number of the call.⁠²²

How do TRICARE’s rules treat habilitation and rehabilitation?

The regulation defines both, which helps when a plan of care is written for a child who never had a skill or an adult who lost one. It defines habilitation as providing functional capacity absent from birth because of a congenital anomaly or developmental disorder, and rehabilitation as reducing an acquired loss of ability.⁠¹¹ PT and OT are cost-shared when the prescribed treatment increases, stabilizes or slows the deterioration of the patient’s ability to perform specified purposeful activity, and the regulation’s rehabilitation benefit covers therapy that improves, restores or maintains function, or prevents its deterioration, when prescribed by a physician.⁠²³

The line TRICARE draws is skill. Occupational therapy to maintain function is covered, but maintenance therapy that no longer needs a skilled level once the program is designed is not.⁠⁷ Write goals that name the function the therapy builds, restores or holds, and document why each visit needs a therapist rather than a home program.

Which TRICARE exclusions should pediatric therapy practices know?

Several of the listed exclusions touch children’s services directly. The OT benefit excludes sensory integration therapy that may be considered part of cognitive rehabilitation; speech therapy excludes myofunctional or tongue thrust therapy, disorders resulting from educational deficits, and special education services from a public educational agency for beneficiaries ages 3 to 21; and the regulation excludes academic education and vocational training generally.⁠^7,8,23 Before scheduling an excluded service for a TRICARE family, such as a myofunctional therapy program, ask the contractor how the exclusion applies, and if you are in the network, read your contract’s terms on non-covered services first.

Do TRICARE patients need a referral for PT, OT or speech therapy?

Yes, in two senses: the therapy needs a prescription or referral from a qualifying clinician under every plan, and TRICARE Prime adds a plan referral and authorization on top. The provider rules set out above require the referral and ongoing oversight for PT, OT and speech therapy whatever the plan, and TRICARE’s speech therapy page tells Prime patients to contact their primary care manager and Select patients their family provider for it.⁠^2,8 The plan rules then differ:

Ask the contractor, not the family, whether a visit needs an authorization. TriWest points providers to a Referral and Authorization Decision Support tool in its Availity portal, asks that follow-up requests list the originally approved diagnosis as the primary diagnosis, and requires the requesting provider to be the one the referral authorized.⁠²⁴ An authorization names a provider and expires: TRICARE tells patients to book with the provider listed in the authorization letter and to get care before the authorization expires.⁠¹⁴

Explain point-of-service charges before a Prime family books without an authorization. Under that option the patient pays an annual deductible of $300 for an individual or $600 for a family, then 50 percent of the allowable charge, and those fees do not count toward the catastrophic cap.⁠³ Active duty family members on Prime pay nothing unless they use the point-of-service option.⁠²⁵

What changes for active duty service members and their families?

Service members follow stricter rules than their families. Active duty service members need a referral for most care received outside their assigned military hospital or clinic, must enroll in TRICARE Prime, and have TRICARE as primary payer even when they hold other insurance.⁠^14,21,25 Their family members can choose Prime or Select.⁠²⁵ Ask about each family member separately, including whether a spouse has employer coverage, which pays before TRICARE.⁠¹⁰

How does TRICARE For Life work for adult therapy patients?

Medicare pays first and TRICARE For Life (TFL) pays second, so an adult TFL patient’s therapy runs on Medicare’s rules before TRICARE’s. TFL is Medicare-wraparound coverage for TRICARE-eligible people who have Medicare Part A and Part B, regardless of age, and it does not extend to family members.⁠²⁶ In most cases the provider files the claim with Medicare, Medicare pays its portion and sends the claim to the TFL claims processor, and TRICARE then pays the provider directly for TRICARE-covered services; patients generally owe nothing for services both programs cover.⁠²⁶

The Medicare side has to be in order first, including the therapist’s Medicare enrollment, which the credentialing guide covers; the Medicare therapy coverage guide explains the patient’s side. Retirees and their families who become eligible for Medicare by age cannot enroll in TRICARE Prime, so an older retiree with Medicare Parts A and B reaches the practice through TFL.⁠^25,26

Two TFL rules change who pays. For a service TRICARE covers and Medicare does not, TRICARE pays the allowable amount and the patient owes the TRICARE deductible and cost-share; and when the patient also has insurance through a current employer, that plan pays first, Medicare second and TRICARE last.⁠²⁶

How do ECHO and the Autism Care Demonstration affect therapy?

Neither replaces the medical benefit that pays for OT, PT and speech therapy. TRICARE’s Autism Care Demonstration (ACD) covers applied behavior analysis as a benefit separate from the TRICARE medical benefit, and TRICARE states that the medical benefit covers occupational therapy, physical therapy and speech therapy for autism spectrum disorder when they are clinically necessary and appropriate.⁠²⁷ The ACD is currently authorized through December 31, 2028, and every TRICARE plan requires a referral and pre-authorization for ABA.⁠²⁷ ABA providers certify under their own categories; Humana Military’s list includes behavior analyst and autism corporate services provider applications, separate from those for PTs, OTs and speech pathologists.⁠¹⁷ The ABA clinic partnerships guide covers working alongside an ABA provider.

The Extended Care Health Option (ECHO) adds services for active duty family members and certain other beneficiaries with qualifying conditions, such as autism spectrum disorder, a moderate or severe intellectual disability or a serious physical disability. The family must enroll in the sponsor’s Exceptional Family Member Program and register with a TRICARE case manager; registration is not retroactive, and every ECHO service needs pre-authorization.⁠²⁸ ECHO benefits include rehabilitative and habilitative services, assistive technology devices and training in their use, all authorized in advance and from TRICARE-authorized providers, and public programs for training, rehabilitation and special education have to be used first when they are available and sufficient.⁠²⁹ When a family asks about equipment or services beyond the basic benefit, send them to their case manager, and keep the therapy plan of care on the medical benefit unless the contractor authorizes something else.

How much does TRICARE pay therapists, and what can you collect?

Up to the allowable charge, which for therapists is the lower of the billed charge or the local CHAMPUS Maximum Allowable Charge (CMAC).⁠⁴ Health.mil describes the CMAC as the maximum TRICARE is allowed to pay for a procedure and says it is tied by law to Medicare’s allowable charges, and the regulation adjusts the national CMAC for localities using Medicare’s geographic areas and adjustment factors.⁠^4,5 The Health.mil look-up prices codes by ZIP code, state or foreign country, with a filter for physical, speech, hearing and occupational therapists.⁠⁵

A rate is not a coverage decision. Health.mil states that the presence of a CMAC rate does not indicate coverage or payment approval, and that the absence of one does not indicate payment denial.⁠³⁰

What you may collect depends on the arrangement. Network and participating providers cannot balance bill; a non-participating provider may bill up to 15 percent above the allowable charge, and the patient pays that difference.⁠³ The regulation ties that limit to Medicare’s limiting charge percentage for nonparticipating practitioners and treats billing above it as abuse or fraud, and grounds for exclusion or suspension.⁠¹² For a Prime enrollee who receives authorized care from a non-participating provider, the allowed amount is the CMAC plus any balance billing amount up to the limit.⁠⁴ Providers also may not seek payment from patients for certain services TRICARE disallows under its utilization review, quality and preauthorization rules.⁠¹²

How do TRICARE claims work with other insurance and deadlines?

File every TRICARE claim within one year of the service, after any other health insurance has processed it. The regulation sets the one-year deadline, says a late claim waives the right to benefits unless the requirement is waived, and allows exceptions.⁠⁹ TriWest says claims go to PGBA for processing, should be filed within one year after the service, must reach PGBA within 90 days of the other insurer’s adjudication, and that a reconsideration request is due within 90 days of the remittance date.⁠²¹

TRICARE pays last. By law it pays after all other health insurance except Medicaid, TRICARE supplements and a few other public programs, and it denies a claim that arrives before the other insurer has processed it.⁠^10,31 Because Medicaid is one of the exceptions, a child with both TRICARE and Medicaid is billed to TRICARE first.⁠¹⁰ The Medicaid enrollment guide and the EPSDT guide cover the Medicaid side. Active duty service members are a second exception: TRICARE is their primary payer and does not coordinate with other insurance.⁠²¹ TriWest makes it the provider’s responsibility to ask whether the patient has other insurance primary to TRICARE, and TRICARE warns that if the other plan denies a claim because its rules were not followed, TRICARE may deny it too.⁠^10,21

Keep the record that supports each claim. The regulation requires clinical records adequate to show that the care was furnished, medically necessary and appropriate, and who provided it, alongside the referral and oversight documentation the referral rule asks for.⁠^2,12

What should your website and intake say about TRICARE?

Exactly what you are, by region and plan, because “we take TRICARE” means something different to a Prime family than to a TFL retiree. A certified non-network practice can treat Select, Reserve Select and TFL patients, while a Prime patient needs a network provider, an authorization or the point-of-service option; calling a certified practice “in network” leaves Prime families open to point-of-service charges they did not expect.⁠^3,6 The insurance and fees guide covers explaining costs to families in plain words.

The same care applies on a DrSensory listing. DrSensory lists clinics, not individual therapists, and one listing covers a practice at one address, so if only some disciplines or therapists at the clinic are TRICARE-authorized, say which. A paid listing adds a description in the clinic’s own words, which is where that statement belongs; a family’s inquiry is read in the clinic’s DrSensory portal and answered from the clinic’s own address. The profile guide covers claiming the free basic listing.

What should intake ask a TRICARE family before booking?

The plan, the sponsor’s status, any other insurance, the prescription and any authorization. Ask the questions in the call script above at the first call, then confirm them with the contractor; the intake call script shows where they fit in a full intake. For a child, the parent or guardian answers; for an adult, the patient answers, along with any helper the patient names.

How might a non-network practice handle three TRICARE callers?

By answering each caller from the plan’s own rules rather than from a single “yes, we take TRICARE.”

How do you keep TRICARE certification current?

Track the triggers for recertification and report every change to the contractor. Humana Military requires recertification when a provider has not submitted claims within two years, starts practicing in a new state, or lets a certification requirement expire.⁠⁶ TriWest publishes forms for updating provider information and for affiliating or disaffiliating a practitioner from a group.⁠¹⁶ The license behind each certification must stay current in each state of practice.⁠²

Sources

1. Defense Health Agency. Become a TRICARE Provider (provider page; it lists the regional contractors as Humana Military for the East Region, TriWest Healthcare Alliance for the West Region and International SOS overseas). Checked October 24, 2026.
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   “At a minimum, all TRICARE providers must be authorized/certified under TRICARE Regulation and must have their authorization/certification status verified by the regional contractors in each region.”; “network providers are placed on the worldwide referral list for all TRICARE beneficiaries.”; “If you decide to become a network provider, you will sign a contractual agreement with the regional contractor in your region.”; “Agree to provide care to TRICARE beneficiaries at a negotiated rate.”; “Accept the beneficiaries’ copayment or cost share as payment in full.”; “File claims with TRICARE for the remaining amount.”; “If you don’t want to sign a contract, you can be a non-network provider, but you must be certified by the regional contractor.”; “Participating providers agree to file claims for beneficiaries, to accept payment directly from TRICARE and to accept the TRICARE allowable charge as payment in full for their services.”; “Non-participating providers do not agree to accept the TRICARE allowable charge or file beneficiary claims.”; “Non-network providers can choose to participate on a claim-by-claim basis. You don’t have to be participating or non-participating all of the time.”; “The regional contractors establish the provider networks and conduct provider education.”; “If you’re already a TRICARE-authorized provider or if you want to become one, call your regional contractor or visit their website, listed below.”
2. Electronic Code of Federal Regulations. 32 CFR 199.6, TRICARE—authorized providers (regulation; eCFR text up to date as of October 22, 2026; paragraph (c), individual professional providers). Checked October 24, 2026.
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   (c)(1)(iii): “otherwise allowable services provided by a CHAMPUS-authorized individual professional provider shall be within the scope of the individual’s license as regulated by the applicable state practice act of the state where the individual rendered the service”; (c)(2)(i): “The individual must be currently licensed to render professional health care services in each state in which the individual renders services to CHAMPUS beneficiaries.”; “The license must be at full clinical practice level to meet this requirement.”; (c)(2)(ii): “When a state does not license a specific category of individual professional, certification by a Qualified Accreditation Organization, as defined in § 199.2, is required.”; (c)(2)(iv): “the physicians must actually see the patient to evaluate and diagnose the condition to be treated prior to referring the beneficiary to another provider”; “Written contemporaneous documentation of the referring physician’s basis for referral and ongoing communication between the referring and treating provider regarding the oversight of the treatment rendered as a result of the referral must meet all requirements for medical records established by this part.”; “Referring physician supervision does not require physical location on the premises of the treating provider or at the site of treatment.”; (c)(2)(v): “a physician or other health care practitioner who is eligible to receive reimbursement for services provided under Medicare”; “shall be considered approved to provide medical care authorized under section 1079 and section 1086 of title 10, U.S.C., chapter 55 unless the administering Secretaries have information indicating Medicare, TRICARE, or other Federal health care program integrity violations by the physician or other health care practitioner.”; “Approval is limited to those classes of provider currently considered TRICARE authorized providers as outlined in 32 CFR 199.6.”; (c)(3)(iii)(K)(2): “may be provided only if: The beneficiary is referred by a physician, certified physician assistant, certified nurse practitioner, or podiatrist; and a physician, certified physician assistant, certified nurse practitioner, or podiatrist must also provide continuing and ongoing oversight and supervision of the program or episode of treatment provided by these individual paramedical providers.”; “Licensed registered physical therapist (PT), including a licensed or certified physical therapist assistant (PTA) performing under the supervision of a TRICARE-authorized PT.”; “Licensed registered occupational therapist (OT), including a licensed or certified occupational therapy assistant (OTA) performing under the supervision of a TRICARE authorized OT.”; “PTAs shall meet the qualifications specified by Medicare (42 CFR 484.115, or successor regulation)”; (c)(3)(iii)(K)(3): “Licensed registered speech therapists (speech pathologists). In order to be considered for benefits on a fee-for-service basis, the services of a licensed registered speech therapist as an individual paramedical provider of care may be provided only if: (1) The beneficiary is referred by a physician, a certified physician assistant, or a certified nurse practitioner; and (2) a physician, a certified physician assistant, or a certified nurse practitioner must also provide continuing and ongoing oversight and supervision of the program or episode of treatment provided by these individual paramedical providers.”
3. Defense Health Agency, TRICARE. Cost Terms (beneficiary glossary, last updated December 12, 2025). Checked October 24, 2026.
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   Allowable charge: “The maximum amount TRICARE will pay a doctor or other provider for a procedure, service, or equipment.”; “Non-participating providers can charge you up to 15% more than the allowable charge that TRICARE will pay.”; “TRICARE sets the CHAMPUS Maximum Allowable Rate for most services. Many rates vary based on location”; Balance billing: “Network and participating providers can’t balance bill.”; “By law, non-participating providers can only bill you up to 15% above the TRICARE-allowable charge.”; Negotiated rate: “making agreements with providers to accept less than the allowable charge for your care.”; Point-of-service fees: “The deductibles are $300 per individual or $600 per family. For services beyond this deductible, you pay 50% of the TRICARE-allowable charge.”; “Point-of-service fees for TRICARE Prime don’t apply toward your catastrophic cap.”
4. Electronic Code of Federal Regulations. 32 CFR 199.14, Provider reimbursement methods (regulation; eCFR text up to date as of October 22, 2026; paragraph (j)(1), the allowable charge method). Checked October 24, 2026.
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   (j)(1)(i)(A): “The allowable charge method is the preferred and primary method for reimbursement of individual health care professionals and other non-institutional health care providers”; “The allowable charge for authorized care shall be the lower of the billed charge or the local CHAMPUS Maximum Allowable Charge (CMAC).”; (j)(1)(i)(C): “Nonparticipating providers may not balance bill a beneficiary an amount which exceeds the applicable balance billing limit.”; (j)(1)(i)(D): “In the case of a TRICARE Prime enrollee (see section 199.17) who receives authorized care from a non-participating provider, the CHAMPUS determined reasonable charge will be the CMAC level as established in paragraph (j)(1)(i)(B) of this section plus any balance billing amount up to the balance billing limit”; (j)(1)(iv)(A): “The national CHAMPUS Maximum Allowable Charge level for each procedure will be adjusted for localities using the same (or similar) geographical areas and the same geographic adjustment factors as are used for determining allowable charges under Medicare.”
5. Military Health System, Health.mil. TRICARE Allowable Charges (CMAC look-up page, last updated July 11, 2023). Checked October 24, 2026.
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   “These charges are the maximum amounts TRICARE is allowed to pay for each procedure or service and are tied by law to Medicare’s allowable charges.”; “Procedure pricing is calculated based on locality.”; “Enter a ZIP Code, select a State, or specify a Foreign Country.”; provider filter: “Therapists (physical, speech, hearing, occupational)”.
6. Humana Military, TRICARE East Region contractor. Provider certification FAQs (PDF, form XPGH0626-A). Checked October 24, 2026.
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   “A copy of licensure is always required.”; “Once the certification process is complete, a provider is considered TRICARE-authorized.”; “Recertification is required for all providers who do not submit claims within a two-year period, or if practicing in a new state, or if your certification requirements have expired.”; “The status of provider when applications are submitted online may be checked via the certification status tracker.”; “No, certification is required for all TRICARE providers. To become a network provider, you must have a contract with Humana Military.”; “Once certified, a provider is classified as TRICARE-authorized non-network. This status allows providers to treat TRICARE Select, Reserve Select and TRICARE for Life beneficiaries.”; for TRICARE Prime or TRICARE Remote beneficiaries, “the provider must be a network provider or the beneficiary must have an authorization or elect to use the point-of-service option under their plan.”; “No, credentialing is only required for network providers who are contracted with Humana Military.”; “Practitioners must meet certification requirements in each practicing state.”; on PTAs and OTAs: “No, only PTA or OTA supervisors are eligible for reimbursement; therefore, a certification application would not be required.”
7. Defense Health Agency, TRICARE. Occupational Therapy (Is It Covered? page, last updated October 2, 2026). Checked October 24, 2026.
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   “Improve, restore, or maintain function”; “Maintain or prevent deterioration of function”; “Must be prescribed and supervised by any of the following TRICARE-authorized providers:”; “Certified physician assistant supervised by a physician”; not covered: “Vocational assessment and training”; “Maintenance therapy that doesn’t require a skilled level after a therapy program has been designed”; “Range of motion and passive exercises that aren’t related to restoration of a specific loss of function”; “Sensory integration therapy that may be considered a part of cognitive rehabilitation”.
8. Defense Health Agency, TRICARE. Speech Therapy (Is It Covered? page, last updated October 1, 2026). Checked October 24, 2026.
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   “TRICARE covers speech therapy to treat speech, language, and voice dysfunctions resulting from birth defects, disease, injury, hearing loss, and pervasive developmental disorders.”; “A referral or prescription is needed before getting speech therapy services. Contact your primary care manager if using TRICARE Prime or your family provider if using TRICARE Select.”; not covered: “Disorders resulting from occupational or educational deficits”; “Myofunctional or tongue thrust therapy”; “Videofluoroscopy evaluation”; “Maintenance therapy that doesn’t require a skilled level after a therapy program has been designed”; “Special education services from a public educational agency to beneficiaries ages 3–21”.
9. Electronic Code of Federal Regulations. 32 CFR 199.7, Claims submission, review, and payment (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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   (d): “all claims submitted for benefits must, except as provided in paragraph (d)(2) of this section, be filed with the appropriate CHAMPUS contractor no later than one year after the services are provided.”; “Unless the requirement is waived, failure to file a claim within this deadline waives all rights to benefits for such services or supplies.”; (d)(2): “The Director, OCHAMPUS, or a designee, may grant exceptions to the claims filing deadline requirements.”
10. Defense Health Agency, TRICARE. Using Other Health Insurance (beneficiary page). Checked October 24, 2026.
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    “By law, TRICARE pays after all other health insurance, except for:”; listing “Medicaid”; and “TRICARE supplements”; “If TRICARE gets your claim before your other health insurance processes it, TRICARE will deny it.”; “If your other plan denies a claim for failure to follow their rules, TRICARE may also deny your claim.”
11. Electronic Code of Federal Regulations. 32 CFR 199.2, Definitions (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “Allowable charge. The CHAMPUS-determined level of payment to physicians, other individual professional providers and other providers, based on one of the approved reimbursement methods set forth in § 199.14 of this part.”; “Habilitation. The provision of functional capacity, absent from birth due to congenital anomaly or developmental disorder, which facilitates performance of an activity in the manner, or within the range considered normal, for a human being.”; “Rehabilitation. The reduction of an acquired loss of ability to perform an activity in the manner, or within the range considered normal, for a human being.”; “A nonparticipating provider looks to the beneficiary or sponsor for payment of his or her charge, not CHAMPUS. In such cases, CHAMPUS pays the beneficiary or sponsor, not the provider.”; “Participating provider. A CHAMPUS-authorized provider that is required, or has agreed by entering into a CHAMPUS participation agreement or by act of indicating ‘accept assignment’ on the claim form, to accept the CHAMPUS-allowable amount as the maximum total charge for a service or item rendered to a CHAMPUS beneficiary, whether the amount is paid for fully by CHAMPUS or requires cost-sharing by the CHAMPUS beneficiary.”
12. Electronic Code of Federal Regulations. 32 CFR 199.6, TRICARE—authorized providers (regulation; eCFR text up to date as of October 22, 2026; paragraph (a), general provisions). Checked October 24, 2026.
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    (a)(1): “The fact that a type of provider is listed in this section is not to be construed to mean that CHAMPUS will automatically pay a claim for services or supplies provided by such a provider.”; “the patient must in fact be an eligible beneficiary and the services or supplies billed must be authorized and medically necessary, regardless of the standing of the provider.”; (a)(6): “providers may not hold patients liable for payment for certain services for which CHAMPUS payment is disallowed.”; (a)(8)(i)(A): “An institutional provider in § 199.6(b), in order to be an authorized provider under TRICARE, must be a participating provider for all claims.”; (a)(8)(ii)(B): “may elect to be a participating provider on a claim-by-claim basis by indicating ‘accept assignment’ on each claim form for which participation is elected.”; (a)(8)(iii): “Individual providers that are not participating providers pursuant to paragraph (a)(8)(ii) of this section may elect to participate on a claim-by-claim basis.”; (a)(11)(i): “The balance billing limit shall be the same percentage as the Medicare limiting charge percentage for nonparticipating practitioners and suppliers.”; (a)(11)(iii): “Failure to comply with the balance billing limit shall be considered abuse and/or fraud and grounds of exclusion or suspension of the provider under § 199.9.”; (a)(12): “shall maintain adequate clinical records to substantiate that specific care was actually furnished, was medically necessary, and appropriate, and identify(ies) the individual(s) who provided the care.”
13. Defense Health Agency, TRICARE. Regions (beneficiary page). Checked October 24, 2026.
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    “TRICARE is managed in three separate regions: the East Region, the West Region, and the Overseas Region.”; “Each region has its own regional contractor.”; “Other contractor partners provide healthcare services and support for TRICARE For Life (in the U.S. and U.S. territories), the Uniformed Services Family Health Plan, and the TRICARE Prime Demo.”; “International SOS is the contractor for the Overseas Region.”
14. Defense Health Agency, TRICARE. Referrals and Pre-Authorizations (beneficiary page, last updated October 7, 2026; its contact panel names Humana Military for the East Region, TriWest Healthcare Alliance for the West Region and WPS Government Services for TRICARE For Life in the U.S. and U.S. territories). Checked October 24, 2026.
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    “A pre-authorization is when your regional contractor approves your care before you go to your appointment.”; “Get care before the authorization expires.”; “Book your appointment with the provider listed in the authorization letter.”; “Note: Active duty service members need a referral for most care received outside of their assigned military hospital or clinic.”; TRICARE Prime, active duty service members: “Yes, for any care your PCM doesn’t provide.”; “If you get care without a referral, you’ll pay out of pocket.”; pre-authorization: “Yes, for all specialty care.”; TRICARE Prime, all other beneficiaries: “Yes, for specialty care and some diagnostic services.”; “If you see a specialist without a referral, you’re using the point-of-service option.”; “Your PCM gets your referral and pre-authorization at the same time.”; TRICARE Select, TRICARE Reserve Select, TRICARE Young Adult-Select, TRICARE For Life and others: “No. Only applied behavior analysis requires a referral.”; pre-authorization list: “All services covered under the Extended Care Health Option”; “Ask you to sign a document to make you pay for authorized services”; “Ask you to sign a document to make you pay for any part of the service TRICARE doesn’t cover”; “Refuse to see you because you won’t sign such a document”.
15. TriWest Healthcare Alliance, TRICARE West Region contractor. TRICARE Non-Network Physical Therapist/Speech Therapist/Occupational Therapist/Audiologist Provider Application (PDF application, submitted by fax or mail). Checked October 24, 2026.
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    “If you have more than one NPI, you must complete a separate application for each NPI number.”; “We expect providers to submit claims electronically.”; “Do you maintain a solo practice?”; “Group Practice Tax ID #”; “The NPI billed on the claim will determine where payment and remittance will be sent.”; “PGBA, LLC must have complete provider documentation on file to determine provider eligibility.”; “Original License Issue Date”; where a state does not license speech pathologists or audiologists: “has a certificate of membership in the American Speech, Language and Hearing Association”; for hippotherapy: “A copy of your certificate from the American Hippotherapy Certification Board is required”; “Without signature authorization forms on file, each claim will require a physical signature from the rendering provider”.
16. TriWest Healthcare Alliance, TRICARE West Region contractor. Non-Network Provider Applications (provider page listing the application forms). “Physical Therapist Assistant (PTA)/Occupational Therapy Assistant (OTA) Provider Application”; “Physical Therapist/Speech Therapist/Occupational Therapist/Audiologist Provider Application”; “Practitioner Affiliation/Disaffiliation Request Form”; “Provider Information Update Request Form”. Checked October 24, 2026.
17. Humana Military, TRICARE East Region contractor. TRICARE Certification and Network Information (provider page; its practitioner applications include Licensed Registered Speech Pathologist (SLP), Occupational Therapist (OT) and Physical Therapist (PT)). Checked October 24, 2026.
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    “All TRICARE-authorized providers must be certified under TRICARE regulation and must have that certified status verified in the East Region.”; “Providers must be TRICARE-certified in order to file claims and receive payment for TRICARE services.”; “TRICARE-authorized certified marriage and family therapists, autism corporate service providers and most institutions (e.g., hospitals, skilled nursing facilities and home health agencies) are required to have a participation agreement with TRICARE (network and non-network).”; practitioner applications: “Certification applications must be submitted online”; ABA applications include “Autism Corporate Services Providers (ACSP) certification”; and “Behavior analyst certification”; virtual health-only applications: “Certification applications must be faxed/mailed”; “Humana Military is not currently accepting requests to join the medical, surgical or ancillary networks.”; “we are taking requests to join these networks.” The last sentence refers to providers who completed TRICARE certification for autism, psychiatry, mental health, substance abuse, doula or lactation services.
18. Defense Health Agency, TRICARE. Virtual Health: Care From Anywhere (beneficiary page). “All referral requirements for virtual health visits are the same as for in-person care.”; “Costs for virtual health visits are the same as for in-person care.” Checked October 24, 2026.
19. TriWest Healthcare Alliance, TRICARE West Region contractor. Join Our Network (provider page). “Fill out the Provider Contract Request form.”; “You will need your Federal Tax ID.”; “You will be contacted by a TriWest provider relations representatives once we have processed your request.”; “TRICARE is administered by TriWest Healthcare Alliance in the West Region.” Checked October 24, 2026.
20. Electronic Code of Federal Regulations. 32 CFR 199.17, TRICARE program (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    (b)(1): “TRICARE Prime is a managed care option that provides enhanced medical services to beneficiaries at reduced cost-sharing amounts for beneficiaries whose care is managed by a designated primary care manager and provided by an MTF or network provider.”; (b)(2): “TRICARE Select is the self-managed option under which beneficiaries may receive authorized basic program benefits from any TRICARE authorized provider.”; (l)(1)(iii): “failure to obtain a primary care manager referral when such a referral is required or seeing a non-network provider when Prime rules require use of a network provider and one is available) will not be paid under Prime rules but may be covered by the point-of-service option.”; (n)(2)(ii): “a beneficiary enrolled in TRICARE Prime is required to obtain a referral for care through a designated primary care manager (or other authorized care coordinator) prior to obtaining care under the TRICARE program.”
21. TriWest Healthcare Alliance, TRICARE West Region contractor. Claims Guidelines (provider page). Checked October 24, 2026.
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    “Claims should be filed within one year after services are provided or within one year of discharge for inpatient admissions.”; “claims must be submitted to PGBA within 90 days of Other Health Insurance (OHI) adjudication.”; “A claim reconsideration must be submitted no later than 90 days from the date of the remittance.”; “TRICARE is the primary payer for active duty service members, including activated National Guard and Reserve members.”; “It is the provider’s responsibility to ask the beneficiary if they have OHI that is primary to TRICARE.”; “If a beneficiary received any excluded or excludable services from a network provider, that provider must not require payment (i.e., the beneficiary will be held harmless)”; “General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or excludable.”
22. Defense Health Agency, TRICARE. Physical Therapy (Is It Covered? page, last updated October 1, 2026). Checked October 24, 2026.
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    “Professionally administered to aid in the recovery from disease or injury”; “A physical therapist assistant performing under the supervision of a TRICARE-authorized PT”; not covered, among others: “General exercise programs”; “Separate charges for instruction of the patient and family in therapy procedures”; “Repetitive exercise to improve gait, maintain strength and endurance, and assistive walking”; “Range of motion and passive exercises not related to restoring a specific loss of function”; “Maintenance therapy”; “Athletic training evaluation”; “Use of powered traction devices”; “Contact your regional contractor for specific limitations to the physical therapy benefit.”; “This list of covered services isn’t all-inclusive.”; “TRICARE covers services that are medically necessary and considered proven.”
23. Electronic Code of Federal Regulations. 32 CFR 199.4, Basic program benefits (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    (c)(3)(x): “Assessment and treatment services of a CHAMPUS-authorized physical or occupational therapist may be cost-shared when:”; “The services are prescribed and monitored by a physician, certified physician assistant, certified nurse practitioner or Doctor of Podiatric Medicine (Podiatrist) acting within the scope of their license.”; “The purpose of the prescription is to reduce the disabling effects of an illness, injury, or neuromuscular disorder; and”; “The prescribed treatment increases, stabilizes, or slows the deterioration of the beneficiary’s ability to perform specified purposeful activity in the manner, or within the range considered normal, for a human being.”; (e)(25): “Rehabilitation therapy as defined in § 199.2 of this part to improve, restore, or maintain function, or to minimize or prevent deterioration of function, of a patient when prescribed by a physician.”; (g)(42): “Self-help, academic education or vocational training services and supplies”; (g)(44): “General exercise programs, even if recommended by a physician and regardless of whether or not rendered by an authorized provider.”; “passive exercises and range of motion exercises also are excluded, except when prescribed by a physician and rendered by a physical therapist concurrent to, and as an integral part of, a comprehensive program of physical therapy.”
24. TriWest Healthcare Alliance, TRICARE West Region contractor. TRICARE Referral and Authorization Guidelines (provider page). “List the originally approved diagnosis as the primary diagnosis.”; “Ensure the requesting provider is the same provider to whom the referral was authorized.”; “Log in to the provider portal, Availity to use the Referral and Authorization Decision Support tool.” Checked October 24, 2026.
25. Defense Health Agency, TRICARE. TRICARE Prime (beneficiary page). Checked October 24, 2026.
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    “TRICARE Prime is a managed care option available in Prime Service Areas.”; “Refers you to specialists for care they can’t provide”; “Works with your regional contractor for referrals and authorization”; “When retired service members and their families become eligible for Medicare based on age, they aren’t eligible to enroll in TRICARE Prime.”; “If you’re on active duty, you have to enroll in TRICARE Prime.”; “All others can choose to enroll in TRICARE Prime or TRICARE Select.”; “Active duty family members pay nothing unless using the point-of-service option.”
26. Defense Health Agency, TRICARE. TRICARE For Life (beneficiary page, last updated September 25, 2026). Checked October 24, 2026.
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    “TRICARE For Life is Medicare-wraparound coverage if you’re TRICARE-eligible and have Medicare Part A and Part B, regardless of age or place of residence.”; “Coverage doesn’t extend to family members.”; “In most cases, your provider files your claims with Medicare.”; “Medicare pays its portion first and sends the claim to the TFL claims processor.”; “TRICARE then pays the provider directly for TRICARE-covered services.”; “Generally, you’ll have no out-of-pocket costs for services that both Medicare and TRICARE cover.”; employer-sponsored insurance with a current employer: “The OHI pays first. Medicare pays second. TRICARE pays last.”; “In the U.S. and U.S. territories: WPS Government Services”. Its cost table shows that for a service covered by TRICARE only, TRICARE pays the TRICARE-allowable amount and the patient pays the TRICARE deductible and cost-share.
27. Defense Health Agency, TRICARE. Autism Care Demonstration (beneficiary page). Checked October 24, 2026.
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    “The TRICARE Comprehensive Autism Care Demonstration covers applied behavior analysis services.”; “TRICARE covered services must be clinically necessary and appropriate.”; “These include occupational therapy, physical therapy, speech therapy, psychological services, psychological testing, and prescription drugs. The TRICARE medical benefit covers these services.”; “ABA services are a benefit covered under the ACD. This is separate from the TRICARE medical benefit.”; “It’s currently authorized to run through Dec. 31, 2028.”; “Your child must get a referral to the ACD and a pre-authorization for all ABA services. All TRICARE plans require this.”
28. Defense Health Agency, TRICARE. Extended Care Health Option (beneficiary page, last updated September 21, 2026). Checked October 24, 2026.
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    “The Extended Care Health Option provides additional assistance to beneficiaries with special needs for an integrated set of services and supplies.”; “Be enrolled in the Exceptional Family Member Program through the sponsor’s service.”; “Register for ECHO with case managers in their TRICARE region or through their USFHP.”; “There’s no retroactive registration for ECHO.”; “You must get pre-authorization from your regional contractor or USFHP for all ECHO services.”; eligible beneficiaries include “Active duty family members”; qualifying conditions include “Autism spectrum disorder”; “Moderate or severe intellectual disability”; “Serious physical disability”.
29. Defense Health Agency, TRICARE. Extended Care Health Option: Benefits (beneficiary page, last updated February 12, 2026). benefits include “Rehabilitative and habilitative services”; “Assistive technology devices”; “Training in the use of special education and assistive technology devices”; all ECHO benefits must be “Authorized in advance, and”; “From a TRICARE-authorized provider”; on public funds and programs: “You must use these resources first if they’re available and sufficient:” Checked October 24, 2026.
30. Military Health System, Health.mil. CHAMPUS Maximum Allowable Charge Rates (rates page, last updated September 9, 2026). “the presence of a CHAMPUS maximum allowable charge rate does not indicate coverage policy nor payment approval”; “Also be advised that the absence of a CMAC rate does not indicate coverage policy or payment denial.” Checked October 24, 2026.
31. Electronic Code of Federal Regulations. 32 CFR 199.8, Double coverage (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    (a)(1): “Congress clearly has intended that TRICARE be the secondary payer to all health benefit, insurance and third-party payer plans.”; (b)(4): double coverage plans do not include “Plans administered under title XIX of the Social Security Act (Medicaid);”; (c)(1): “TRICARE benefits may not be extended until all other double coverage plans have adjudicated the claim.”

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. TRICARE contractors and their processes change; confirm each step with your regional contractor before relying on it.