Clinical Care Support Program Referral Form

TriWest offers Clinical Care Support Programs that are specifically designed for those individuals who would benefit from additional medical management assistance. Our programs provide support and education to improve beneficiary health outcomes. These programs include: Care Coordination, Case Management (complex, transplant, ECHO and Autism), Condition (Disease) Management, and Tobacco and Vaping Cessation Support.

Use this form for CARE MANAGEMENT SUPPORT PROGRAMS requests only. This form should NOT be used to request a specific provider or to submit referrals or claims. If used for any purpose other than requesting a support program, submissions will be disregarded.

To refer a beneficiary for one of our programs, complete the Clinical Care Support Program Referral Form. Once submitted, our clinical staff will review your request, determine eligibility and begin appropriate program outreach through the identified contact information provided.

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Clinical Care Support Programs

Care Coordination: Short-term transition of care assistance, inpatient transfers, post-discharge needs, transfer from one TRICARE Region to another, etc.

Case Management: Longer-term engagement with beneficiaries who have complex needs. These engagements can be associated with mental and/or physical health diagnoses.

Condition (Disease) Management: Engagement with beneficiaries with specific chronic conditions to provide health and wellness education and guidance to provide the best outcomes and self-management skills.

Extended Care Health Option (ECHO): Initial requests for new beneficiary registration in the ECHO. The beneficiary must be an active duty family member, and Exceptional Family Member Program (EFMP) enrollment is required in most cases.

Tobacco and Vaping Cessation Support: Engagement with beneficiaries who are interested in discontinuing the use of tobacco, nicotine, and/or vape. Support is provided through health education and empowered guidance on quitting and the use of self-management skills.

NOTE: While the Autism Care Demonstration (ACD) is a care support program, a TRICARE approved provider must submit the initial care referral as an authorization/referral with supporting documentation to start the process, which is followed by ACD Care Support program enrollment. Learn more about Autism Care Demonstration.

Fields with an asterisk (*) are required.

Beneficiary First and Last Name *

Beneficiary Date of Birth

Program*

Beneficiary Contact Preference*

Describe the Reason for Referral *

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Beneficiary First and Last Name *

Beneficiary Date of Birth *

Program*

Sub-Program*

Beneficiary Contact Preference*

Beneficiary Phone*

Beneficiary Email*

Beneficiary - Portal Notifications *

Describe the Reason for Referral*

Please be assured that TriWest takes all concerns seriously and will thoroughly investigate the matter and take all appropriate actions. Due to federal and/or state privacy regulations, we are unable to share the results of our investigation or actions taken as it pertains to a clinical quality program.

The Information collected with this form is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information shall be considered for official use only and protected accordingly. Any individual responsible for unauthorized disclosure or misuse of this information may be subject to a fine of up to $50,000 and/or other sanctions as appropriate.