Referral, Prior Authorization and Inpatient Notification Requirements
On Feb. 20, 2018, the Defense Health Agency implemented a temporary waiver of outpatient referral and authorization requirements for TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan.
- Please review our TRICARE Prime Referral Waiver page for details and guidelines on how to access care during the waiver period.
- The Prior Authorization, Referral and Benefit Tool below may be used to verify TRICARE-covered services, but the referral and authorization guidelines displayed for TRICARE Prime beneficiaries may not apply during the waiver period.
Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends you to see a cardiologist to evaluate a possible heart problem.
The referral may be either:
Evaluation only – These referrals are for the initial evaluation, to include required diagnostic services, but not treatment. This type of referral also includes requests for second opinions.
Evaluation and treatment – These referrals are for the initial evaluation, required diagnostic services and treatment related to a specific medical condition.
All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must have a referral from their PCM before seeking care from other professional or individual paramedical providers. Most specialty services for TRICARE Prime beneficiaries, regardless of where they live, require an approval from Health Net Federal Services, LLC (HNFS).
Important Things to Remember about Referrals
- With an approval from HNFS, you may be directed to receive care at a military hospital or clinic. View the Referrals to Military Hospitals and Clinics page for more details.
- TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must see TRICARE network providers when available in order to avoid additional costs. View the Out of Network Requests page for more details.
- The Point of Service (POS) option allows TRICARE Prime beneficiaries to self-refer to any TRICARE network or non-network provider for medical/surgical or mental health services without referrals from their PCMs or HNFS. Beneficiaries who use the POS option will pay a deductible and have higher cost-shares for services. The POS option does not apply to active duty service members, so they may be responsible for the entire cost of care.
Prior authorizations are for certain services and/or procedures that require HNFS review and approval, prior to being provided. Some services and/or procedures that require approval include certain mental health care, hospitalization, surgical, and therapeutic procedures.
Note: Please review our Supplemental Health Care Program page for updates to the active duty service member approval process.
Inpatient Notification Process
Health Net Federal Services requires notification of inpatient facility admissions and discharge dates by the next business day following the admission and discharge. Health Net Federal Services will conduct continued stay reviews for all mental health care and other services. Clinical records will be requested as necessary.
When are both a prior authorization and a referral required?
Both are required when a TRICARE Prime, TRICARE Prime Remote or TRICARE Young Adult Prime beneficiary receives a referral to a specialist and the specialist wants to perform a service on the prior authorization list. For example, a PCM referral is needed to see a general surgeon, and a prior authorization is needed if the surgeon wants to perform weight loss surgery.
Prior Authorization, Referral and Benefit Tool
To determine if a service requires an approval from HNFS, use the Prior Authorization, Referral and Benefit Tool.