Referral and Prior Authorization Requirements
Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends you to see a cardiologist to evaluate a possible heart problem.
The referral may be one of the following:
Evaluation 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.
Evaluation and treatment – 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.
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
- You 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. In the rare case that network providers are not available or there is a clinically significant reason care must be provided by a non-network provider, clear and detailed documentation must be provided for consideration of this request.
- The Point of Service (POS) option allows TRICARE Prime beneficiaries to self-refer to any TRICARE network or non-network provider for medical/surgical or mental health services without referrals from their PCMs or HNFS. Beneficiaries who use the POS option will pay a deductible and have higher cost-shares for services. The POS option does not apply to active duty service members, so they may be responsible for the entire cost of care.
Prior authorizations for certain services and/or procedures require Health Net Federal Services, LLC (HNFS) review and approval, prior to being provided.
Note: Please review our Supplemental Health Care Program page for information on the active duty service member approval process.
- TRICARE Prime beneficiaries (including TRICARE Prime Remote and TRICARE Young Adult Prime): A prior authorization from HNFS is required for inpatient facility admissions (excluding emergency admissions). Notification of emergency admissions and discharge dates must be submitted by the next business day following admission and discharge.
- TRICARE Select beneficiaries (including TRICARE Reserve Select, TRICARE Retired Reserve and TRICARE Young Adult Select): An approval from HNFS is not required for inpatient facility admissions. However, notification of admissions and discharge dates must be submitted by the next business day following the admission and discharge.
HNFS conducts continued stay reviews for all mental health care and other services. Clinical records will be requested as necessary.
Prior Authorization, Referral and Benefit Tool
To determine if a service requires an approval from HNFS, use the Prior Authorization, Referral and Benefit Tool.