Prior Authorization, Referral and Benefit Tool
Coronavirus (COVID-19) testing reminder:
TRICARE covers medically necessary and appropriate testing. Beneficiaries suspected to have COVID-19 should be tested following Centers for Disease Control and Prevention (CDC) guidelines. You do not need an approval from HNFS for medically necessary testing.
The Prior Authorization, Referral and Benefit Tool allows you to easily determine HNFS approval requirements
Note: View our Approval Requirements for Ancillary Services page for approval requirements specific to ancillary services, such as diagnostic laboratory tests and radiology. We offer this supplemental list to help providers who already have an approval from HNFS to determine whether a separate referral is required for these services.
Requirements (Referrals vs. Prior Authorizations)
Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends a patient to see a cardiologist to evaluate a possible heart problem.
How many visits and the type of treatment allowed depends on how HNFS approves the request:
Evaluation only – Allows for two office visits with the specialist to evaluate the beneficiary and perform diagnostic services, but not treat. This type of referral includes diagnostic/ancillary services that do not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and one follow up visit for that established patient.)
Evaluation and treatment – Allows for one evaluation visit with the specialist and five follow-up visits. This type of referral includes subsequent care (diagnostic and ancillary services, related procedures) that does not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and five follow up visits for that established patient.)
Procedure only – Allows for the test/procedure only.
Second opinion – Allows for one evaluation visit with the specialist and one follow-up visit.
Important things to remember about referrals:
- Visit our Episode of Care page for examples that can help you understand referrals and when to submit a new request to HNFS.
- Beneficiaries may be directed to receive care at a military hospital or clinic.
- TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must see TRICARE network providers when available. If a non-network provider is requested for a TRICARE Prime beneficiary and there are network providers available within access standards, then care may automatically be redirected to a network provider.
- The Point of Service (POS) option allows TRICARE Prime beneficiaries (excluding active duty service members) to self-refer to any TRICARE network or non-network provider for services without referrals from their PCMs or HNFS.
Prior authorizations for certain services and/or procedures require Health Net Federal Services, LLC (HNFS) review and approval, prior to being provided. Check to see if we offer a Letter of Attestation you can attach instead of clinical documentation. This will expedite the review process.
Note: Please review our Supplemental Health Care Program page for information on the active duty service member approval process.
Network and non-network providers who submit claims for services without obtaining the required prior authorization will receive a 10 percent payment reduction during claims processing.