TriWest and TRICARE in San Antonio: who to call and what they do

When you hear TRICARE, you might assume there is one central organization that handles everything. In practice, TRICARE is administered regionally through managed care support contractors. For San Antonio and the rest of the TRICARE West region, that contractor is TriWest Healthcare Alliance. Understanding who TriWest is and what they handle prevents confusion when you are trying to get coverage verified or prior authorization processed quickly.

What TriWest is and what they do

TriWest Healthcare Alliance is a private company under contract with the Defense Health Agency (DHA) to administer TRICARE benefits in the West region, which covers 21 western and midwestern states including Texas. San Antonio, as part of the TRICARE West region, is under TriWest’s administration.

TriWest’s responsibilities include maintaining the network of TRICARE-certified civilian providers, processing claims from those providers, conducting prior authorization reviews for covered services, managing continued stay reviews for inpatient treatment, and handling beneficiary customer service for the West region.

TriWest does not set TRICARE policy. The Defense Health Agency sets coverage policy. TriWest implements it. This distinction matters for appeals. If TriWest denies a prior authorization, the appeal goes to TRICARE, not back to TriWest.

What TriWest handles for addiction treatment specifically

Prior authorization

Before entering inpatient detox or residential treatment, TriWest must authorize the admission. This is the most important role TriWest plays in the addiction treatment process. The authorization process works like this: you or the facility calls TriWest, provides your TRICARE member ID and clinical information, and TriWest reviews whether the requested level of care meets TRICARE’s medical necessity criteria. The review typically takes 24 to 48 hours for standard requests. Urgent clinical situations can be expedited same-day.

PHP and IOP often require prior authorization as well. Standard outpatient therapy generally does not. Always call TriWest to confirm what is required before starting any level of care above standard outpatient.

Provider network management

TriWest maintains the list of in-network substance use treatment providers in the San Antonio area. Network status determines your cost-sharing. In-network providers have contracted rates, out-of-network providers can charge more. To verify whether a specific facility is in-network, call TriWest directly with the facility’s name and NPI number. The TRICARE provider directory at tricare.mil is a starting point, but TriWest can give you the most current network status.

Claims processing

After treatment, the facility submits claims to TriWest. TriWest processes the claim against your plan’s cost-sharing rules and sends an Explanation of Benefits (EOB) to you. If a claim is denied (as opposed to a prior authorization denial), you have 90 days to appeal to TRICARE. TriWest can help you understand what the claim denial means, but the appeal itself is handled through TRICARE.

Continued stay reviews

During inpatient residential treatment, TriWest conducts periodic reviews, typically every 5 to 7 days, to assess whether continued inpatient care is medically necessary. The facility submits clinical documentation and TriWest approves or denies continued coverage. If a continued stay review results in a denial, the facility should assist you in appealing and planning the transition to the next appropriate level of care.

Military treatment facilities vs TriWest-covered civilian facilities

Not all care in San Antonio goes through TriWest. Note that the military treatment facilities, including San Antonio Military Medical Center (SAMMC) at Fort Sam Houston and Wilford Hall Ambulatory Surgical Center at Lackland AFB, are part of the Military Health System and are administered separately from TriWest’s civilian provider network.

For active-duty service members receiving care at military treatment facilities, the branch substance abuse programs (ASAP, ADAPT, SARP) coordinate care internally. TriWest becomes relevant when the military treatment facility refers to a civilian provider for a level of care not available at the MTF.

For TRICARE Select retirees and dependents, military treatment facilities and civilian TriWest-network providers are both options. Cost-sharing may differ between them. Care at MTFs is typically free or lower cost than civilian network care for most beneficiaries.

What to say when you call TriWest

When you call TriWest at 1-888-874-9378 about addiction treatment, the following information helps move the call forward efficiently:

Your TRICARE member ID number, the sponsor’s Social Security number or DOD ID number, the name and NPI number of the facility you are considering, the level of care (detox, residential, PHP, IOP), and your PCM’s name if you are enrolled in TRICARE Prime. If you are not certain of the level of care, you can describe the situation and ask TriWest what authorization is required for that type of care.

Ask specifically: “Is this facility in-network with TriWest?” and “What prior authorization is required before admission?” and “What is my expected cost-sharing for this level of care under my plan?” Getting these three answers before admission covers the most common sources of billing confusion.

When TriWest denies and what happens next

If TriWest denies prior authorization for a level of care, that denial is not final. You have the right to a formal clinical appeal through TRICARE. The appeal goes to TRICARE, not back to TriWest, and is reviewed by a TRICARE medical director.

TriWest is required to send you a written denial notice that explains the clinical reason for the denial and your appeal rights. Read this notice carefully and act within the deadline, typically 90 days from the denial date for standard appeals. See our step-by-step guide on how to appeal a TRICARE denial for the full process and what to include.