Understanding the Referral/Authorization Request Process

TriWest Healthcare Alliance offers a convenient and secure online referral and authorization tool that enables registered users to submit requests efficiently, allowing them to concentrate on patient care. The tool provides:

• Faster response times; in most cases, your request is processed immediately
• Instant confirmation that TriWest has received your referral or authorization request
• Real time status of referral/authorization requests

The preferred way of submitting referral and authorization requests is online via the secure provider portal at www.triwest.com/provider. Providers should submit referral and authorization requests with supporting clinical documentation for these services.

As a refresher, remember that a referral is the process of the primary care manager sending a patient to another professional provider for consultation or a health care service when the requested service is outside the scope of practice for the referring provider. A prior authorization is required for requested services, procedures, or admissions for a TRICARE beneficiary that require medical necessity review before services are rendered.

Authorizations are required for procedures listed on the Prior Authorization List (PAL) for all TRICARE beneficiaries in programs administered by TriWest; specialists are required to obtain authorization before performing any procedure listed on the PAL. Providers should submit authorization requests with supporting clinical documentation. When using the online referral and authorization tool, documents can be electronically attached. If using the fax process, please include the clinical information along with the TRICARE Patient Referral/Authorization form.

Here are some important points to understand about submitting your referrals and authorizations online:

• Always enter a reason and/or clinical information to support your request. Requests for active duty Service members (ADSMs) require as much information as possible on every request. This allows the Military Treatment Facility (MTF) to assess whether the service may be provided within the MTF as well as assess fitness for duty for the ADSM. Not providing this information can delay the completion of your request.
• Please either copy and paste clinical information from your system or type in a brief description in the notes section explaining your reason for the referral or authorization request. You may also attach office notes or photos to your online request. Supporting documentation may be attached in typical file formats: MS Word, JPG, TIF, PDF.
• Only office visits, outpatient care, and pre-admission requests can be entered via the referral and authorization online tool. The actual inpatient admission notification still needs to be faxed to TriWest.
• If you are not the beneficiary's primary care manager (PCM) and are not an ordering practitioner, you should identify the referring provider in the note field. You should not request services outside your scope of practice or self refer.

Click here for more information regarding the online referral/authorization submission tool.

If submitting your requests online is not available to you, please include clinical information when faxing the TRICARE Patient Referral/Authorization Form to TriWest.

Avoiding Delays

The following guidelines will help expedite your referral and authorization requests:

• Be specific about the requested services and provide the most appropriate procedure and diagnosis codes. Requests for durable medical equipment (DME) also require complete information on applicable codes. A reasonable range is acceptable. Include National Drug Codes (NDCs) for medication requests.
• Make sure the correct ICD-9 and Current Procedural Terminology (CPT®) code(s) are included. Be sure to clearly reference your contact information. Incomplete forms may slow the process.
• Use relevant clinical information forms, available under the “Find a Form” tab at www.triwest.com/provider, to assist you in providing the necessary information for TriWest to process your requests.
• When pictures are needed to support the requested service, the preferred method of submission is to use the online referral and authorization tool and attach a digital photograph to the request. If that is not possible, mail photographs to the appropriate TriWest hub office. Pictures sent via fax do not transmit clearly and may delay the process while TriWest requests and awaits receipt of originals.

If you have any questions or need more information about referral and authorization requirements and the submission process, please visit the Referrals/Authorizations section of www.triwest.com/provider, the online Provider Handbook at www.triwest.com/provider or call 1-888-TRIWEST (874-9378).