We work the TRICARE claims Cheyenne practices pick up from base referrals: missing referrals, other-health-insurance holds, TRICARE For Life claims that never crossed over, and the 365-day limit.
Not sure where your TRICARE balances stand? Start with a free audit.
Quilven is not affiliated with F.E. Warren AFB, the 90th Medical Group, the Defense Health Agency, TRICARE or TriWest.
TRICARE rules
Patients referred from the base arrive on different TRICARE plans, and each plan pays under a different rule. Whether a claim pays depends on the patient's plan, their category, and whether the right referral or authorization was on file at the time of the visit. Each block below states one rule and where it comes from.
The 90th Medical Group runs an outpatient clinic for more than 10,500 beneficiaries and refers care to providers across Cheyenne and the Front Range. Active-duty members, their families and retirees all arrive with different TRICARE plans, so a single practice can be billing three sets of rules in the same week.
Source: fewarren.tricare.mil, About Us
Specialty care needs a referral from the patient's primary care manager. Some services also need TriWest pre-authorization. For active-duty service members, all civilian specialty care needs a referral. Check requirements in the RADS tool on Availity before the visit.
Source: TriWest provider handbook: Provider Information; Referrals and Authorizations
A Prime enrollee seen without a referral is covered under the point-of-service option: a $300 deductible ($600 per family), then 50% of the TRICARE allowable charge. Active-duty service members can't use the point-of-service option.
The AR effect: a missing referral turns a routine TRICARE claim into a large patient balance, or into no coverage at all for an active-duty patient. Get the referral on file before the visit.
Source: tricare.mil FAQ
No referral is needed to see a TRICARE-authorized provider. Some services still need pre-authorization, so a Select claim can still deny for a missing authorization.
Source: TriWest provider handbook
Network providers follow TriWest's agreement. Non-network participating providers accept the TRICARE allowable as payment in full. Non-participating providers can bill up to 15% above it.
Medicare pays first. Original Medicare claims cross over to the TRICARE For Life processor, WPS. Medicare Advantage claims don't cross over, so the secondary claim has to be filed with WPS separately. A For Life balance sitting unpaid after Medicare Advantage paid is often a claim that was never sent.
Source: tricare.mil FAQ · WPS TRICARE For Life, EDI
For VA community care, the state employee plan and statewide payers, see Cheyenne's other payers.
Engagement
The steps follow the AR recovery method, worked remotely inside your EHR. Only the TRICARE sorting changes.
TRICARE AR is sorted by plan (Prime, Select, For Life) and by patient category (active duty, family member, retiree). The rules differ for each, so the sort decides which rule a claim is worked against.
Every Prime claim is checked for a referral or authorization number before it is reworked. A claim with no referral on file is a different problem from a claim with a coding error.
Claims held for other-health-insurance flags are separated from true denials. The fix starts with the patient's coverage record, not the claim.
For Life secondaries from Medicare Advantage patients are filed with WPS directly instead of waiting for a crossover that will never come.
Each claim is tracked against the 365-day limit and the 90-day window after the other insurer pays. Whichever closes first sets the order of work.
Claims left over from the 2025 contractor change are covered in unpaid TriWest claims.
Comparison
A process comparison drawn from one engagement outside Wyoming that did not involve TRICARE. Not a record of a Cheyenne practice and not a promise of outcome.
| Area | Before | With Quilven |
|---|---|---|
| Rejection ownership | No one was assigned to the rejection queue, and claims sat in it for most of a year. | Rejections are worked within four to five days, while the 365-day TRICARE limit is still open. |
| Coordination of benefits | Other-coverage details were never updated with the patient, so the same claims denied again. | Other-health-insurance holds are cleared and TRICARE is billed second within 90 days, with the primary EOB attached. |
| Payer routing | Claims were sent to a parent plan when a subsidiary with its own claims unit was responsible. | For Life secondaries from Medicare Advantage patients are filed with WPS directly. |
| Eligibility | Patients were seen after their coverage had ended, and the claims went out regardless. | Plan, patient category and referral are confirmed before the visit. |
| Member and group IDs | One member ID formatting error stayed on file for months. | Demographic fields are matched to the payer's record before the claim is sent. |
| Lab claim attribution | The group NPI was entered where the ordering physician's belonged, with a CLIA level that did not fit the code. | The ordering physician's NPI is in box 17 and the CLIA level fits the code billed. |
| Modifiers | Waived lab tests went out without QW, and 25, 59 and RT were left off where required. | Modifiers are checked by code family before submission. |
| Timely filing | Rejections surfaced long after the fact, with no proof of the first submission on file. | TRICARE's 365-day and 90-day secondary windows are tracked per claim, with proof of submission kept. |
Which of these applies to your TRICARE claims is a question the audit answers.
Deadlines
A TRICARE claim is recoverable while its window is open, or if you can prove it was filed in time. For a retiree on TRICARE For Life, the Medicare limit runs first. See which TRICARE claims are still workable.
| Rule | Deadline | Source |
|---|---|---|
| TRICARE West claim to PGBA | 365 days from date of service | TriWest handbook |
| TRICARE as secondary | 90 calendar days from the other insurer's adjudication date | TriWest handbook |
| Late TRICARE claims | Timely filing waiver, only for the conditions TriWest lists | TriWest waiver form |
| TRICARE claims in general | Within one year of service in the US | tricare.mil claims page |
| Medicare (For Life primary) | 12 months from date of service | 42 CFR 424.44 |
Last checked: 11 Oct 2026
Before writing off any TRICARE balance, check each claim against its window.
Case study
One AR recovery engagement, at a family medicine practice in Minnesota. Not Cheyenne, and not TRICARE. Shown for method. Individual results vary. One engagement is not a forecast.
Method. We started by sorting 245 claims by why each one stopped, before reworking any of them. The rejection queue had no owner, and some claims had waited close to a year.
Root cause. Most denials began at the front desk: out-of-date coverage, wrong member IDs and skipped eligibility checks accounted for 70% of them.
Found. The unworked queue held roughly $40,000 to $50,000 in billed charges.
Limit. On most of the affected claims, the filing window had closed with no proof of submission on file, so no appeal was possible.
Recovered. About $5,500 was paid on 50 to 55 claims, most of it within 45 to 50 working days.
I appreciate the professionalism, the courtesy, the knowledge.
What you have provided for me was a detailed of things that are going wrong that needed to change in our practice.
I appreciate that you did an audit and found out the root causes of a lot of my problems which are preventable.
Pricing
Same pricing as every Quilven engagement, with nothing TRICARE-specific. You can see pricing in full.
12 to 15%
of the recovered amount
No fee on what is not recovered. Where a practice lands in the range depends on claim volume, age of the inventory, and payer mix.
3 to 5%
of collections by monthly volume
A $500 monthly minimum applies. The rate moves with monthly volume, not with headcount on your side.
$150 to $250
per provider per payer
Priced per enrollment so you can see exactly what each payer application costs before it starts.
Fit
Recovery work does not require a system swap. We integrate with 30+ EHRs and practice management systems and work inside the one you already have. No data migration, no parallel system, no change to how your staff enters a charge or checks a patient in. If your team is trained on your current software, that training stays valid.
This matters because the usual objection to outside AR help is that it turns into an implementation project. It does not here. Quilven is a managed service, not software. There is no proprietary platform you are asked to adopt and no license to renew, so the engagement can start on your existing inventory rather than after a build-out.
What you do get is visibility. Apex is our client dashboard, and it shows in real time:
Apex reads the work we are doing in your system. It is a window, not a replacement, so if the engagement ends your records and workflows are exactly where they were.
Company
Quilven is a managed revenue cycle service. Not software, not an EHR, and not a proprietary platform you have to adopt. We work inside the system your practice already uses, across 30+ integrations, with no data migration and no workflow change. Our clients are independent practices with 3 to 25+ providers.
Pricing is straightforward. AR recovery is 12 to 15 percent of the recovered amount. Medical billing is 3 to 5 percent of collections by monthly volume, with a $500 monthly minimum. Credentialing is $150 to $250 per provider per payer.
The entry point is a free RCM audit. It takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, so the first thing you get from us is a diagnosis you can act on with or without us.
We lead with method and evidence rather than tenure. Quilven was founded in 2025 by Raief Shick and works from 159 4th Ave N, Suite 100, Nashville, TN 37219. The entity is registered in Wyoming. Reach us at (202) 490-9406 or info@quilven.com.
QUILVEN, LLC is registered in Wyoming. Our office is in Nashville, and Wyoming practices are served remotely, inside their own EHR.
Fit
Independent Cheyenne and Front Range practices with 3 to 25+ providers that take TRICARE referrals from the base or see retirees on TRICARE For Life, and whose TRICARE balances are aging with no one assigned to sort them by plan and window.
It suits specialists whose Prime claims stall on referrals, and primary care practices carrying For Life secondaries that never crossed over from Medicare Advantage.
It is not for military treatment facilities, or for hospitals billing facility claims.
At a glance
FAQ
Next step
The audit takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, plus the repeating root causes behind your denials. We only need aging totals to begin. No patient data, no contract, no obligation to work with us afterward. If your aging is healthy we will tell you that.
Answer three questions below and book a line-by-line audit of your TRICARE claims.
Pick the one that hurts most. We start there.
A round number is fine. We verify it in the audit.
Just you, or a group. Either is welcome.
No patient data. We only need aging totals to start.
(202) 490-9406 · info@quilven.com · Book 15 minutes