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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.

  • Attach the LOA to to your online authorization request or return as directed in your request for additional information letter.
  • Be sure to complete the LOA in its entirety, inluding the beneficiary information, diagnosis and medical necessity rationale for the requested services or supplies.
  • Sign the letter to attest to the accuracy of the clinical information. 

We do not offer LOAs for all services. As additional limited benefits are identified for which an LOA is appropriate, we will add to the list below. Please be sure to use the most recent copy of the LOA when submitting a request, as requirements and benefits can change.

 

Provenge® is a registered trademark of Dendreon Corporation.
Spravato® is a registered trademark of Janssen Pharmaceuticals Inc.
Synagis® is a registered trademark of MedImmune, LLC.
Varithena® is a registered trademark of Boston Scientific Corporation.