The short answer
Most unpaid TRICARE West claims fall into four groups: never received, held for other health insurance, denied, or past a filing window. Each group has a different fix, so sorting comes before rework.
Two deadlines decide what is left. A claim must reach PGBA within 365 days of the date of service. When TRICARE pays second, it must reach PGBA within 90 calendar days of the other insurer's adjudication. Both are set out in the TriWest TRICARE provider handbook.
What happened in 2025
TriWest Healthcare Alliance took over the 26-state TRICARE West Region on 1 January 2025. In the early months of the year, a Defense Health Agency spokesperson said, problems loading provider files into contractor systems led to a backlog of more than a million claims (Stars and Stripes, 3 May 2026). In spring 2025, the American Speech-Language-Hearing Association reported provider complaints about TriWest payments, credentialing and the provider portal.
The same DHA spokesperson said TriWest and Humana Military have met claims timeliness requirements since July 2025. The Stars and Stripes report also described complaints about claims held for other health insurance flags continuing into 2026.
The practical point is the calendar. Claims from late 2025 are reaching their 365-day limit now. A claim with a 1 October 2025 date of service must reach PGBA by 1 October 2026. A claim from 15 December 2025 closes on 15 December 2026. Any claim from the transition months that is still unpaid should be sorted this month, not next quarter.
The deadlines
Four TriWest rules decide whether an aging TRICARE West claim is still workable.
| Rule | Detail | Source |
|---|---|---|
| Filing limit | 365 days from date of service (inpatient facility: from discharge) | TriWest handbook |
| TRICARE as secondary | 90 calendar days from OHI adjudication | TriWest handbook |
| Late claims | Timely filing waiver, only for the conditions TriWest lists, with documentation | TriWest waiver page |
| Processing standard | 98% of retained and adjustment claims processed within 30 calendar days of receipt | TriWest handbook |
Last checked on tricare.triwest.com: 29 Sep 2026
Use the processing standard as a trigger. If a claim has had no response 30 days after PGBA received it, check its status in Availity rather than waiting longer. You can run the 365-day and 90-day math for each claim in the browser.
Sort every unpaid claim into one of four buckets
Put each unpaid TRICARE West claim in exactly one bucket before anyone reworks it. The bucket decides the next action.
- 1
No record or rejected
Check the claim's status in Availity. If PGBA has no record of it, the claim was never received, so it has not started processing. Resubmit it, and keep the proof of the original submission with it in case the 365-day limit is close.
- 2
Held for other health insurance
The flag sits on the patient's coverage record, not on the claim, so reworking the claim does not clear it. TriWest's guidance is that if you believe the OHI record is wrong, you contact the beneficiary to update their OHI. Once the record is cleared, resubmit. If the other coverage really exists, bill it first, then bill TRICARE within 90 calendar days of its adjudication.
- 3
Denied
Read the denial reason on the remittance. A correctable error, such as a code, modifier or ID, gets a corrected claim. A decision you dispute goes to reconsideration, which TriWest says must be submitted no later than 90 days from the date of the remittance.
- 4
Past 365 days
A timely filing waiver applies only when one of the conditions TriWest lists fits: retroactive eligibility or authorization issued after the deadline, a patient who was mentally incompetent with no legal guardian, proof the claim was submitted before the deadline, or an OHI EOB received within the deadline with the claim sent within 90 days of the OHI decision. If none fits, write the claim off with a documented reason.
Some 2025 denials traced back to the provider's credentialing or network status, not the claim itself. Check the provider record before reworking a batch of similar denials.
Last checked on tricare.triwest.com: 29 Sep 2026
The proof you will need
Every bucket except the first depends on documents. Keep these for each TRICARE claim, retrievable by claim number:
- Clearinghouse acceptance reports and 277CA acknowledgments, per claim
- The primary payer's EOB, showing its adjudication date
- Referral or authorization numbers for the episode of care
- A log of status checks, with dates and what each one showed
First-handIn one AR recovery engagement outside the West Region, a commercial payer's filing window had closed on most affected claims with no proof of submission on file, so the appeals could not be won. Proof on file is often what decides how much old AR is collectible.
Practices near a base carry more of this
Practices near military installations see more TRICARE volume, so unpaid TRICARE West AR concentrates there. When a military treatment facility refers care out to civilian specialists, each referral becomes a TRICARE claim for the practice that sees the patient.
One example: the F.E. Warren Medical Group at F.E. Warren Air Force Base works with a referral network of providers across Cheyenne and the Front Range (fewarren.tricare.mil). For how that plays out, see TRICARE-heavy AR in Cheyenne.