March 19, 2018
Area(s) of Interest: Patient Care Payor Contracting Payor Issues and Reimbursement
Since the transition of TRICARE managed care services from United Health Military & Veterans (UMVS) to Health Net Federal Services (HNFS) on January 1, 2018, physicians have reported significant delays in processing of authorizations and referral requests, which is affecting patient care.
To address the delays, the Defense Health Agency has waived authorization and referral request requirements for all outpatient TRICARE-covered services from January 1 through March 31, 2018, for TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan. DHA had originally waived the requirements only until March 18, but the California Medical Association learned recently that the temporary waiver has been extended through March 31.
Through March 31, 2018, providers will no longer need to submit referral or authorization requests for TRICARE Prime patients seeking TRICARE-covered outpatient services with some exceptions. Authorizations and referral requests will still be required for inpatient care, applied behavior analysis, laboratory developed test and Extended Health Care Option services.
For requests submitted prior to February 20, 2018, that are still pending, the TRICARE West Region Referral/Authorization Waiver Approval Letter serves as your approval.
According to the HNFS Frequently Asked Questions (FAQ), TRICARE Prime enrollees can obtain covered outpatient services from any TRICARE-authorized provider (network or non-network) during the waiver period with the following documentation:A written referral or order for covered procedures, services or equipment dated between January 1, 2018, and March 31, 2018. A copy of the TRICARE West Region Referral/Authorization Waiver Approval Letter.
Referrals issued by providers between January 1 and March 31, 2018, are valid through June 15, 2018. For care that extends beyond June 15, 2018, or for referrals issued after March 31, 2018, providers will need to follow the prior established TRICARE referral and authorization requirements and obtain approval.
HNFS will host several provider webinars regarding the TRICARE West authorization and referral process focusing on the TRICARE and HNFS referral requirements and online resources available to assist in verifying requirements, submitting requests and checking status.
To register, please visit the Online Provider Education on the TRICARE West For Providers website.
For more information on the TRICARE transition, see CMA's TRICARE Transition Guide, available free to members inCMA's online store.
Contact: CMA’s reimbursement helpline (888) 401-5911 or email Economic Services.