TRICARE Prime Outpatient Referral Waiver
The Defense Health Agency’s temporary TRICARE Prime referral waiver ended April 15, 2018. This waiver allowed TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan to bypass the Health Net Federal Services, LLC (HNFS) review and approval process when referred by their provider for most specialty outpatient care. (For beneficiaries enrolled to a military primary care manager (PCM), the waiver period ended April 1, 2018.)
What does this mean for West Region TRICARE Prime enrollees?
If you received a referral for covered outpatient specialty care between Jan. 1, 2018 and April 15, 2018, and you/your provider used the TRICARE West Region Referral/Authorization Waiver Approval Letter as verification of approval, that referral is valid through June 30, 2018 (or through postpartum care for outpatient maternity referrals).
Your doctor will only need to submit an approval request to HNFS if you need care past June 30, 2018 (or after postpartum care). Additionally, because we worked through our referral backlog during the waiver period, any approval notice received from HNFS during the waiver period remains valid through its expiration date, and your provider does not need to submit a new request.
TRICARE Prime referral and authorization rules
TRICARE Prime enrollees must follow Prime referral and authorization guidelines for any new specialty services referred by their military PCM as of April 2, 2018, or by their civilian PCM as of April 16, 2018, or Point of Service charges may apply.
We offer a Prior Authorization, Referral and Benefit tool to help you verify referral and authorization requirements.
Providers should not resubmit requests for services already covered under an active HNFS approval. If your provider previously submitted outpatient requests via fax, please note we now only accept online requests.
Frequently Asked Questions
- Who was impacted by the waiver?
TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan, including active duty service members.
- Did the waiver apply to all TRICARE-covered services for TRICARE Prime beneficiaries?
No. The waiver did not apply to inpatient care, or ABA, LDT or ECHO* services. For these services, providers must continue to submit requests to HNFS.
*Services covered under the basic TRICARE benefit, such as physical, occupational and speech therapy, were covered under the waiver, even when the beneficiary is registered in ECHO.
- How did a TRICARE Prime beneficiary initiate care during the waiver period?
TRICARE Prime beneficiaries could seek covered outpatient services from any TRICARE-authorized provider (network or non-network) with the following documentation:
- A written referral or order for covered procedures, services or equipment from the beneficiary’s provider dated between Jan. 1, 2018 and April 15, 2018
- A copy of the TRICARE West Region Referral/Authorization Waiver Approval Letter
- What if I received an approval from HNFS prior to the waiver period?
If you received an approval from HNFS prior to Feb. 20, 2018, please continue to honor the parameters of that approval. The TRICARE West Region Referral/Authorization Waiver Approval Letter did not replace approvals already issued by HNFS.
- What did HNFS do with requests submitted prior to the waiver period that hadn't processed?
HNFS processed pending referral and athorization requests. As a result, beneficiaries and providers may have been issued determination letters during the waiver period. Approvals issued during this time are valid through their expiration dates.
- If I scheduled specialty care using the waiver, but then received a determination from HNFS (from a previously-submitted request), which do I follow?
TRICARE Prime beneficiaries who started treatment using the waiver can continue with that treatment and disregard the HNFS determination notice. Keep in mind, the waiver does not cover services that do not meet TRCARE coverage criteria.
- How do we determine referral/authorization effective dates for those issued during the waiver period?
The waiver approval letter allows for care through through June 30, 2018 (or through postpartum care for outpatient maternity referrals). For care referred during the waiver period that extends beyond June 30, 2018, your provider must submit a request to HNFS for approval.
- Will HNFS’ online tools reflect referrals and authorizations issued during the waiver period?
Except for ABA, LDT and ECHO services, our online tools at www.tricare-west.com will not reflect referrals/orders for outpatient services given to TRICARE beneficiaries by civilian and military providers during the waiver period. The TRICARE West Region Referral Waiver Approval Letter is your verification of approval.