TRICARE Prime Outpatient Referral Waiver
The Defense Health Agency’s temporary TRICARE Prime referral waiver ended April 15, 2018. This waiver period allowed TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan to bypass the Health Net Federal Services, LLC (HNFS) review and approval process for most specialty outpatient care.
Continuity of care
Beneficiaries who began covered outpatient services with your written referral or order dated between Jan. 1, 2018 and April 15, 2018, and a copy of the TRICARE West Region Referral/Authorization Waiver Approval Letter, are approved to continue care through June 30, 2018 (or through postpartum care).
Providers only need to request a new approval from HNFS if that care extends past June 30, 2018 (or through postpartum care). We ask you not to resubmit requests for services that are already covered under an active HNFS approval or covered under the waiver. Your cooperation with these guidelines can help reduce the amount of unnecessary requests received and expedite beneficiaries’ access to care.
Submitting requests to HNFS
New referrals and orders issued to your TRICARE Prime patients on or after April 16, 2018, must follow TRICARE Prime referral and authorization guidelines. Point of Service charges and authorization penalties may apply if the required HNFS approval is not obtained. We offer two online options for submitting requests to HNFS:
- CareAffiliate® – Log in with your www.tricare-west.com account information to quickly and easily submit and track status of prior authorizations, referrals, and inpatient and discharge notifications.
- Web Authorization/Referral Form (WARF) – Providers and staff without a www.tricare-west.com account can use WARF to submit outpatient requests.
Find our step-by-step guide to using CareAffiliate, and a Request Profile Guide should you use WARF, on our How to Submit a Request page.
If you previously submitted outpatient requests via fax, please note we will only accept online requests as of April 16, 2018.
Remember, not all specialty care referrals require HNFS review. Please verify approval requirements with the Prior Authorization, Referral and Benefit tool.
Frequently Asked Questions
- Who was impacted by the waiver?
The TRICARE West Region Referral/Authorization Waiver Approval Letter was valid for 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.
*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.
- What were the dates of the referral waiver period?
For military providers, the waiver covered most outpatient specialty care referrals for TRICARE Prime patients issued between Jan. 1–April 1, 2018. For civilian providers, it covered referrals issued between Jan. 1–April 15, 2018. For both military and civilian provider referrals, care approved under the TRICARE West Region Referral/Authorization Waiver Approval Letter is valid through June 30, 2018.
- How did a TRICARE Prime beneficiary initiate care?
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
Note regarding beneficiaries enrolled to/referred by a military primary care manager (PCM): Per DHA’s direction, as of April 2, 2018, military hospital and clinic PCMs resumed submitting referral requests to HNFS for approval.
- 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 a TRICARE Prime patient scheduled specialty care using the waiver, but then received a determination from HNFS (from a previously-submitted request), which does he/she follow?
If a beneficiary started treatment using the waiver, he/she 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 June 30, 2018 (or through postpartum care for outpatient maternity referrals). For care referred during the waiver period that extends beyond June 30, 2018, the referring 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.
- During the waiver period, I referred my TRICARE Prime patient for specialty care and used the waiver letter as the approval. Now that the waiver period is over, do I have to let HNFS know about that referral or submit a request to get that referral approved?
No. The waiver approval letter serves as your approval, and allows for care through June 30, 2018. Please do not submit/ resubmit requests for services that are already covered under an active HNFS approval or covered by the waiver approval letter. (Note: If your patient requires care beyond June 30, 2018 (or postpartum care), you will need to submit a new request to HNFS prior to June 30.)
- If I don’t need to submit a request to HNFS, how will my claim(s) for services referred under the waiver get paid?
HNFS and its claims partner, PGBA, have system indicators in place to ensure claims received for covered specialty services will process as if a referral was on file.
- Do I need to include the waiver approval letter when submitting my claim?
No. The waiver approval letter is for your records only as proof of authorization. We do not need it for claims processing purposes.
- Do I need a www.tricare-west website account to submit new requests to HNFS?
While we recommend you register at www.tricare-west.com to get access to CareAffiliate®, our comprehensive referral and authorization submission tool, providers can use our Web Authorization/Referral Form to submit requests without a login. All requests must be submitted online. As of April 16, 2018, we do not accept faxed requests.