TRICARE Referrals and Authorizations

If a necessary service or procedure cannot be provided by a MTF or the beneficiary’s PCM, a referral to another provider for services can be required depending on the beneficiary program option (see below). Various procedures and services require pre-authorization from TriWest before they can be administered.

Referral and authorization requirements differ by TRICARE program option:

• TRICARE Prime: Referrals are required from a beneficiary’s PCM before seeking care from other providers
• TRICARE Select: Referrals are not required to seek care from TRICARE authorized providers
• Certain services require pre-authorizations depending on the program option

Providers can check the  Referral and Authorization Decision Support (RADS) tool to view the Pre-Authorization List to determine authorization requirements before performing services.

Referral and Pre-Authorization Requirements

Providers must comply with all referral and pre-authorization requirements contained in:

• TRICARE policy requirements
• TriWest published policy and procedures
• TriWest TRICARE Provider Handbook

Providers are encouraged to review these policies and procedures routinely as changes may occur due to contract modifications. Additionally, TriWest reviews pre-authorization requirements annually, ensuring adherence to TRICARE policy. To ensure appropriate utilization of care, TriWest also evaluates medical and behavioral health care trends.

Beneficiaries may be directed to receive care at a MTF if the specialty service requested is offered and the MTF accepts the beneficiary. If the MTF cannot provide the requested care, TriWest will find a network provider.

It is the provider/PCM’s responsibility to obtain a pre-authorization for services that require them. Per TRICARE Reimbursement Manual Chapter 1, network and non-network providers who do not obtain a pre-authorization and submit a claim for services that require them will receive a 10% payment reduction during claims processing. Network providers may have a greater penalty depending on the provider’s network contract. Payment reduction penalties cannot be passed onto the beneficiary.

Submitting Referral and Pre-Authorization Requests

Referrals and pre-authorizations can be submitted to TriWest using the online referral management system on Availity. Supporting clinical documentation must be attached to the request. If further documentation is needed, or if further instructions are required, TriWest will notify the PCM or referring provider.

MTFs can coordinate pre-authorizations and referrals with TriWest based on the specific guidelines established in the Memorandums of Understanding (MOU) between TriWest and their MTF.

The PCM or referring provider is responsible for providing the following information for services that require a pre-authorization or referral:

• Written explanation of the services that are being requested
• Sufficient clinical information to aid the beneficiary’s treatment

The PCM or referring provider must also ensure the beneficiary is prepared for the appointment by ensuring they have the medical records, laboratory results or X-rays, etc., needed. If needed, TriWest will contact the provider’s office for further information or clarification to process the pre-authorization or referral request.

Once the referral request or pre-authorization is approved, TriWest sends a notification to the beneficiary and referring provider/PCM that lists:

• Specialty provider’s name
• Specialty services
• Dates and visits that are approved

TriWest also posts provider letters in the online referral management system online. Beneficiary letters are posted to the secure beneficiary portal that is accessible through https://tricare-bene.triwest.com/signin.

For outpatient services, the letter includes an authorization number for the approved services. Beneficiaries can use the information in the letter to schedule their first appointment. If they require assistance, providers are expected to help them schedule the service. For letters notifying the beneficiary of a denied authorization, guidance on how to submit an appeal is included.

For inpatient services, after TriWest is notified of a beneficiary’s admission, the letter will include a tracking number for the pre-authorization request.

Required Clinical Documentation

Because TRICARE coverage of certain limited benefits is subject to specific clinical criteria review, TriWest may require providers to complete clinical information assessments. These assessments can be accessed via the online referral management system on Availity. The provider must:

• Complete the beneficiary information
• Provide the diagnosis and medical necessity rationale for the requested services or supplies
• Electronically sign the assessment to confirm the accuracy of the clinical information

This assessment is submitted with a pre-authorization request.

MTF Optimization/KSA Referrals

Military hospitals and clinics, generally known as military treatment facilities (MTFs), are usually located on or near military installations. The TRICARE provider network supplements MTF resources to ensure that beneficiaries get the care they need.

MTFs are located on most military posts, bases, and installations with the goal of active duty readiness for military contingency operations. They also have primary responsibility for providing care to TRICARE beneficiaries within their capabilities and capacities. To provide care effectively and efficiently, MTFs retain the right to accept referrals for TRICARE beneficiaries when they have the capabilities and capacity to provide the required services. These referrals are known as Knowledge, Skills, and Abilities (KSA) referrals. Important reasons that MTFs may choose to deliver Prime-referred services include:

• To ensure all medical service forces are ready to perform by keeping their skills current
• To ensure MTF optimization, which helps to contain health care cost for TRICARE beneficiaries
• To assist in determining prevalent MTF specialty access and adequacy needs for a particular TRICARE population
• To enhance the military graduate medical education program
• To hone the skills of military providers rotating through the MTF

If the MTF cannot provide the requested services, the beneficiary will be referred to a TriWest network provider. However, if a TriWest network provider is selected before the MTF optimization determination and the MTF opts to provide the services, this overrides any prior network provider selection, and the beneficiary is required to be seen at the MTF.

TRICARE Prime beneficiaries who have received a referral for services will be referred by TriWest to an MTF first when the MTF indicates they have the capability to provide that type of care. The MTF has the right to accept or refuse the referral.

Providers are expected to refer TRICARE Prime beneficiaries to TRICARE network providers, except in an emergency or where the provider has obtained a referral or pre-authorization. If a Prime beneficiary chooses to receive a covered service from a non-network provider without a referral, the service will be covered under their Point of Service (POS) option. ADSMs who do not coordinate care through their PCMs may be responsible for the entire cost of care.

Referrals to non-network providers for TRICARE Prime beneficiaries must include specific medical necessity and justifying information as to why a non-network provider must be used instead of a TRICARE network provider.

TRICARE Prime Referral Processing

When TRICARE Prime beneficiaries need specialty care referrals, the requesting provider must submit a referral/authorization request to TriWest for approval, which includes possible MTF Optimization/KSA referral processing.

Providers must request referrals using the TriWest online referral management system on Availity to include appropriate clinical information.

Processing Timelines for Pre-Authorization and Referral Requests

TriWest will process requests in the following time frames:

• Routine referral requests are processed within one-to-two business days of receiving the request from the provider.
• Urgent referral requests are processed within one business day.
• Routine authorization requests are processed within two-to-five business days of receiving the request from the provider and all required clinical documentation.
• Urgent authorization requests are processed in an accelerated manner for care that needs to be delivered within 72 hours. Processing time for both routine and urgent requests may be delayed if sufficient information is not provided.
• Requests are processed using the clinical information submitted by the provider

Appeals and Reconsideration

Beneficiaries have the right to file an appeal (also known as reconsideration) to dispute a denial of pre-authorization for services. TRICARE defines an appeal as a formal written request by a beneficiary, a participating provider, a provider denied authorized provider status under TRICARE, or a representative, to resolve a disputed question of fact.

Please see TOM Chapter 12 for more information on TRICARE appeals requirements.

Depending on the situation, an appeal may be urgent, non-urgent expedited, or non-expedited.  This depends on whether the care has already been received and the situation’s urgency. TriWest provides instructions for filing the request for reconsideration in the notification letter.

TriWest can receive appeals via fax or email. These requests must include:

• Beneficiary’s name, address, phone number, and sponsor’s Social Security number (SSN) or DOD Benefits Number (DBN)
• Printed name of the person submitting the appeal and the relationship to the beneficiary
• Reason for disputing the denial (required)
• Copy of the initial denial letter and any other documents related to the issue
• Additional documents supporting the appeal

Active Duty Service Member Reconsiderations

TRICARE Prime Remote (TPR) beneficiaries may have the right to a reconsideration if their request for services was denied. They can contact DHA-Great Lakes at 888-647-6676 for answers to questions or to initiate a reconsideration. Providers who submit reconsiderations on the behalf of a service member must obtain an Appointing a Representative for an Appeal form.