Durable Medical Equipment: When to Request Approval from HNFS

Thursday, December 6, 2018

Health Net Federal Services, LLC (HNFS) has recently noticed an increase in the number of authorization requests for durable medical equipment (DME), prosthetics, orthotics and medical supplies, also known as DMEPOS. Medically necessary DMEPOS are a limited benefit under TRICARE and authorization requirements vary by plan type. Physicians, dentists or any TRICARE-authorized allied health care professional may order or prescribe DMEPOS when acting within the scope of their license or certification. Please review the following to avoid submitting unnecessary approval requests. 

The authorization process
Only beneficiaries enrolled in TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime require approval from HNFS for DMEPOS. 

  • Exception: Approval is not required for those items considered inexpensive according to Centers for Medicare and Medicaid Services (CMS) guidelines. View the CMS DMEPOS Fee Schedule at www.cms.gov for details.  
  • Verify beneficiary eligibility and prior authorization requirements using the Check Eligibility and Prior Authorization, Referral and Benefit tools before submitting requests to HNFS.

Required documentation 
If prior authorization is needed, submit the request online using CareAffiliate® (preferred) or the Web Authorization and Referral Form (WARF).

  • If using CareAffiliate, attach the provider script or order using the Assessment, Notes or Attachment feature.
  • If using WARF, include the name of the ordering military or civilian provider in the Clinical Documentation Required Field. (WARF does not allow for attachments.)

All durable equipment orders/prescriptions are considered valid for one year. Beneficiaries should return to their PCM annually to determine if ongoing treatment is required. Retroactive dates, if needed, should be indicated in the provider’s notes on the request. Point of Service charges may apply if an HNFS approval is not on file at the time services are incurred (when required). 

Certificate of medical necessity
A certificate of medical necessity (CMN) is required for any DMEPOS item with a purchase price of over $150, and all rental items regardless of price. Though no specific CMN form is required, a valid CMN should include:

  • The beneficiary’s diagnosis, specific equipment needed, length of time needed, and a valid provider name or signature. Providers must be TRICARE-authorized MDs, DOs or other allied health care professionals.  

Learn more about benefit coverage, limitations and exclusions on our Durable Medical Equipment Details page.