Requirements (Referrals vs. Prior Authorizations)
Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends a patient to see a cardiologist to evaluate a possible heart problem.
How many visits and the type of treatment allowed depends on how HNFS approves the request:
Evaluation only – Allows for two office visits with the specialist to evaluate the beneficiary and perform diagnostic services, but not treat. This type of referral includes diagnostic/ancillary services that do not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and one follow up visit for that established patient.)
Evaluation and treatment – Allows for one evaluation visit with the specialist and five follow-up visits. This type of referral includes subsequent care (diagnostic and ancillary services, related procedures) that does not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and five follow up visits for that established patient.)
Procedure only – Allows for the test/procedure only.
Second opinion – Allows for one evaluation visit with the specialist and one follow-up visit.
Important things to remember about referrals:
- Visit our Episode of Care page for examples that can help you understand referrals and when to submit a new request to HNFS.
- Beneficiaries may be directed to receive care at a military hospital or clinic.
- TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must see TRICARE network providers when available. If a non-network provider is requested for a TRICARE Prime beneficiary and there are network providers available within access standards, then care may automatically be redirected to a network provider.
- The Point of Service (POS) option allows TRICARE Prime beneficiaries (excluding active duty service members) to self-refer to any TRICARE network or non-network provider for services without referrals from their PCMs or HNFS.
Prior authorizations for certain services and/or procedures require Health Net Federal Services, LLC (HNFS) review and approval, prior to being provided. Check to see if we offer a Letter of Attestation you can attach instead of clinical documentation. This will expedite the review process.
Note: Please review our Supplemental Health Care Program page for information on the active duty service member approval process.
Network and non-network providers who submit claims for services without obtaining the required prior authorization will receive a 10 percent payment reduction during claims processing.