Requirements (Referrals vs. Pre-authorization)
Referrals
Referrals are for services that are not considered primary care. For example, a primary care manager (PCM) sends a patient to a cardiologist to evaluate a possible heart problem.
HNFS referral types:
Evaluate 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.)
Evaluate and treat – 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:
- Providers can 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 see any TRICARE network or non-network provider without referrals from their PCMs or HNFS.
Pre-authorization
Certain services and/or procedures require Health Net Federal Services, LLC (HNFS) review and approval, or pre-authorization, before the services are rendered. 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 pre-authorization will receive a 10 percent payment reduction during claims processing.
