Overview:

At Lab Revenue Navigator, our Payor Policy Research team recently investigated TriWest’s prior authorization requirements—and the results are a critical reminder for any lab performing Laboratory Developed Tests (LDTs) for Tricare beneficiaries.

Key Policy Updates from TriWest:

• Pre-authorization is mandatory for all LDTs, with the exception of cystic fibrosis testing.

• For repeat LDTs conducted on the same beneficiary, appropriate modifiers must be used.

• Claims submitted without prior authorization will be denied.

TriWest currently does not offer a downloadable document or CPT-specific portal for verifying prior auth requirements. This creates potential risk for labs who rely on assumptions or inconsistent guidance.

“A LDT is an In Vitro Diagnostic (IVD) test that is designed, manufactured, and used within a single laboratory.” – TriWest

Additionally, TriWest confirmed that it follows Medicare billing guidelines for all services, including medical necessity criteria.

Action Steps for Labs:

1. Audit your test catalog and identify which procedures fall under the LDT category.

2. Set up workflows to ensure prior authorization is obtained before submission.

3. Educate billing teams on modifier usage and TriWest’s reliance on Medicare policies.

4. Stay alert to any future updates as TriWest expands access to CPT verification tools.