Episode of Care Examples
The below examples can help you understand when and when not to submit a new request to Health Net Federal Services, LLC (HNFS). Use our Prior Authorization, Referral and Benefit Tool to determine requirements.
Example 1 (evaluate and treat)
A military hospital/clinic provider refers a retired service member with chest pain to a cardiologist, specifying “evaluate and treat.” In order to make a complete assessment, the cardiologist orders diagnostic laboratory tests, an echocardiogram, a holter monitor and a routine treadmill test as part of the evaluation. The cardiologist does not need a separate approval from HNFS to perform these tests. Why?
- The primary care manager (PCM) specified “evaluate and treat” on the original referral.
- Laboratory tests (excluding laboratory developed tests), echocardiograms, holter monitors and routine treadmill tests do not require pre-authorization for this beneficiary category. (Use our Ancillary Services Approval Requirements tool to verify approval guidelines.)
- The services are TRICARE covered benefits.
- The cardiologist performed the services within the duration of the approved PCM referral.
Tip: For the same reasons, the cardiologist may also perform outpatient cardiac catheterization procedures to diagnose and/or treat the heart condition without requesting approval from HNFS. (Cardiac catheterization is a TRICARE-covered benefit that does not require pre-authorization).
Example 2 (specialist-to-specialist)
The cardiologist in Example 1 identifies the need for surgical intervention as a result of cardiac catheterization findings. The patient must now be referred to a cardiothoracic surgeon. In this case, the cardiologist or PCM must submit a new referral for the cardiothoracic surgeon to HNFS. What changed?
- The original specialist (the cardiologist) does not perform the needed service and is requesting evaluation from a new type of specialist (cardiothoracic surgeon). Therefore, a new referral is required.
- This request must also go through the right of first refusal (ROFR) process and be reviewed for military hospital/clinic capability and capacity.
Example 3 (diagnostic radiology)
An orthopedist at a military hospital/clinic is treating an active duty service member with shoulder pain. The orthopedist determines the patient requires an MRI. The MRI does not need a separate approval from HNFS. Why?
- An MRI is a diagnostic radiology service logically associated with shoulder pain.
- The beneficiary only needs an order for the MRI, not approval from HNFS. The MRI can be administered under an "evaluate and treat" referral as part of the episode of care.
A military hospital/clinic or civilian PCM refers a non-active duty service member with low back pain to a civilian orthopedist. The orthopedist determines the beneficiary requires physical therapy and durable medical equipment (DME) as part of conservative therapy. In this case, although the services are related to the episode for which the beneficiary was originally referred, approval from HNFS is required. The orthopedist – not the PCM – must submit a request to HNFS. What changed?
- Physical therapy and DME are not diagnostic services.
- The original specialist (the orthopedist) does not perform the needed service.
- The request must go through the right of first refusal (ROFR) process and be reviewed for military hospital/clinic capability and capacity.