Referrals to Military Hospitals and Clinics
Health Net Federal Services, LLC (HNFS) will first attempt to coordinate care at a military hospital or clinic for TRICARE Prime beneficiaries who live near a military facility and are referred for specialty care, inpatient admissions or procedures requiring an approval. Therefore, if the provider submits a prior authorization or referral request to HNFS, the beneficiary may be referred to the military hospital or clinic for care, regardless of whether a civilian network provider is requested. If the services are not available at the military hospital or clinic, the care will be coordinated with a TRICARE network provider. This coordination of services is also known as the right of first refusal process.
- TRICARE Prime beneficiaries (includes TRICARE Prime Remote active duty family members and TRICARE Young Adult Prime):
Regardless as to whether the TRICARE Prime beneficiary has a military or civilian primary care manager (PCM), the military hospital or clinic has the opportunity to review each request to determine if it can provide the service. If the TRICARE Prime beneficiary, excluding active duty service members, does not wish to receive his or her care from the military hospital or clinic, he or she can choose to use his or her Point of Service (POS) option or disenroll from TRICARE Prime.
Note: The POS option will only apply to those services that require an approval. For example, ancillary services will not incur POS charges if the beneficiary chooses to receive care from a civilian network provider.
- TRICARE Select, TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult Select:
These beneficiaries can self-refer to a TRICARE network or TRICARE-authorized non-network provider and do not have to obtain care at the military hosptial or clinic. By using TRICARE network providers, TRICARE Select beneficiaries can save on their out-of-pocket costs.
How Does This Process Work?
When a provider submits a request to HNFS on behalf of a TRICARE Prime beneficiary, the request is forwarded to the military hospital or clinic and is reviewed to determine if the facility can provide the service(s). The military facility will notify HNFS in a timely manner if it can provide the service.
If it is determined the military hospital or clinic can provide the service, HNFS will complete the request and the beneficiary will be advised to contact the MTF to schedule an appointment. If the military hospital or clinic is not able to provide the service, HNFS will complete the referral to a civilian network provider and notify the beneficiary so he or she can schedule the appointment.
Important Things to Remember
- TRICARE Prime beneficiaries who live within a 60-minute drive time should always consider the military hospital or clinic their first option for all referred care, even if they have been seeing a civilian provider for other related care.
- Even if the provider requests a civilian provider, the TRICARE Prime beneficiary may be referred to the military hospital or clinic if the care is available there.
- TRICARE Prime beneficiaries should not schedule an appointment with a civilian network provider who is not the PCM until they have received an approval from HNFS.