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Letters of Attestation

TRICARE coverage of certain limited benefits is subject to specific clinical criteria. A letter of attestation (LOA) can be submitted by the provider, in lieu of additional clinical documentation, when requesting authorization from Health Net Federal Services, LLC (HNFS) for these services.

The provider must complete the beneficiary information, provide the diagnosis and medical necessity rationale for the requested services or supplies, and then sign the letter to attest to the accuracy of the clinical information. This letter can then be attached to your online authorization request. Please be sure to use the most recent copy of the LOA (see list below) when submitting a request, as the requirements and benefits can change.

A letter of attestation is not available for all services. As additional limited benefits are identified for which an LOA is appropriate, they will be added to the list below. 

Letters of attestation are available for:

 

Provenge® is a registered trademark of Dendreon Corporation.

Synagis® is a registered trademark of MedImmune, LLC.