Letters of Attestation

TRICARE coverage of certain limited benefits is subject to specific clinical criteria. A letter of attestation (LOA) can be submitted by the provider, in lieu of additional clinical documentation, when requesting authorization from Health Net Federal Services, LLC (HNFS) for these services.

• Attach the LOA to your online authorization request or return as directed in your request for additional information letter.
• Be sure to complete the LOA in its entirety, including the beneficiary information, diagnosis and medical necessity rationale for the requested services or supplies.
• Sign the letter to attest to the accuracy of the clinical information. 

We do not offer LOAs for all services. As additional limited benefits are identified for which an LOA is appropriate, we will add to the list below. Please be sure to use the most recent copy of the LOA when submitting a request, as requirements and benefits can change.

• Abortion
• Assisted reproductive technology (ART)
• Autism definitive diagnosis (Autism Care Demonstration: Definitive Diagnosis Referring Provider Attestation)
• Automated external defibrillator
• Bariatric surgery
• Bariatric revision surgery
• Bone growth stimulator (electronic)
• Bone growth stimulator (ultrasonic)
• Botox
• Breast MRI – diagnostic
• Breast MRI – screening
• Breast prosthesis replacement
• Circumcision
• Cochlear implants
• Continuous glucose monitor
• Coronavirus (COVID-19) antibody (serology) test
• CT angiography of the heart
• Diabetes self-management training
• Diabetic shoes
• ECHO home health care (agency)
• ECHO home health care (provider)
• Electroconvulsive therapy (ECT)
• Eye glasses or contacts
• Femoroacetabular impingement (FAI) surgery
• Home health
• Home sleep study
• Hysterectomy
• Insulin pump
• Laboratory developed tests (single and panel)
• Lung cancer screening (low-dose CT)
• Lung volume reduction surgery
• Maintenance of wakefulness testing (active duty only)
• Mammogram (screening, 2D or 3D)
• Mastectomy (prophylactic)
• Medically necessary food/nutritional counseling
• Nail trimming
• Non-network care (including continuity of care)
• Osteoporosis screening
• Otoplasty
• Preconception and prenatal carrier screening
• Provenge^®
• Prosthetic/orthotic
• Prothrombin time (PT)/international normalize ratio (INR) monitoring device
• Radiofrequency denervation (non-pulsed)
• Sacral nerve stimulation
• Spravato^®
• Synagis^®
• Thoracic sympathectomy
• Transcranial magnetic stimulation (TMS)
• Travel benefit (TRICARE Prime beneficiaries)
• Varicose Veins
• Varithena®
• Ventricular assist device
• Vertebroplasty or balloon kyphoplasty

^{_{Provenge® is a registered trademark of Dendreon Corporation.
Spravato® is a registered trademark of Janssen Pharmaceuticals Inc.
Synagis® is a registered trademark of MedImmune, LLC.
Varithena® is a registered trademark of Boston Scientific Corporation.}}