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Thank you. Your Clinical Support Program Referral Form has been submitted successfully. Clinical staff will evaluate your request and verify eligibility.

Clinical Care Support Program (CCSP) Referral Form

TriWest offers Clinical Care Support Programs that are specifically designed with you in mind. Our programs provide support and education to improve your health and wellness. The support programs include Care Coordination, Case Management, and Condition (Disease) Management. The CCSP Form is for requesting Care Coordination, Case Management, and Condition (Disease) Management Program support, only.

Do not use the CCSP form:

  • If you are requesting a specific provider
  • To check the status of current care or program enrollment
  • To submit referrals or authorizations
  • To file or check the status of claims
  • To file or check the status of a grievance or appeal
  • To inquire about eligibility and benefits

If you are currently enrolled in a CCSP, please do not submit a new CCSP Form. Duplicate submissions will not be accepted and will not receive a response. For urgent assistance, please call 888-TRIWEST (874-9378).

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. This program includes the following sub-programs: Complex Case Management, Mental Health Case Management, Transplants, or Extended Care Health Option (ECHO).

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.

NOTES:

  • 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.
  • Do not submit a referral for Extended Care Health Options (ECHO) if you are retired, a retired family member, or an active duty service member.
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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.