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Prior Authorization, Referral and Benefit Tool

The tool allows you to easily determine HNFS approval requirements.

Requirements (Referrals vs. Prior Authorizations)
 

Referrals

Referrals are for services that are not considered primary care. For example, a primary care manager (PCM) sends a patient to a cardiologist to evaluate a possible heart problem.

HNFS referral types:

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:

  • Providers can 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 see any TRICARE network or non-network provider without referrals from their PCMs or HNFS. 


Prior Authorizations

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.