Outpatient TRICARE Service Request/Notification Form

When requesting a prior authorization or referral for outpatient health care services, providers should complete the Outpatient TRICARE Service Request/Notification Form and then print and fax the form to Health Net Federal Services, LLC at 1-888-299-4181.

Note: Health Net only accepts ICD-10 diagnoses on service requests from civilian providers for services on or after October 1, 2015. Codes are preferred over the equivalent written description. ICD-9 codes are only acceptable for services prior to October 1, 2015.

  • Created: Nov 24, 2015
  • Modified: Nov 24, 2015
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