January 22, 2009

The referral and authorization letter that beneficiaries and providers are accustomed to seeing is changing. 

Currently, the beneficiary and requesting and servicing providers, as well as a facility (as applicable), receive separate letters for each service requested within each authorization and referral processed. Effective January 19, 2009, the beneficiary and provider will receive only one referral/authorization letter that will contain status information on all the services within the request, except for medically denied services. Here is an example of the letter.

For six months following the new letter implementation, all beneficiaries receiving a referral/authorization letter will also receive the attached sample letter that provides a detailed explanation of the new letter format. If the same beneficiary receives more than one referral/authorization letter in the same six-month period, he/she will not be given another copy of the sample letter.

Here is some information about the letters:

1. The new letter process is only for those services that are not medically denied. Medical denials will continue to generate separate letters.
2. The new letter process does not change the current inpatient/preadmission process. Those letters will continue in their current format.
3. There will be a base letter that is sent out when the request is initially completed.
4. There will be a modification letter that is sent out to providers and beneficiaries when any updates are done to the request. They are the same, except for one line explaining why a new letter was generated.
5. Providers/Facilities will receive a copy of the letter mailed to the beneficiary. Letters will no longer have provider/facility specific versions although they will have additional content that is either included or excluded depending on the type of service. Provider letters have consult tracking fax cover sheets. Beneficiaries do not have the fax cover sheets. Beneficiaries get an appeal rights worksheet, but providers do not.
6. We have added quantity and the specialty type to these letters. Please note that specialty type can be Multispecialty or Acute Care Facility, which may be confusing to some beneficiaries.
7. The letters are not intended to provide educate. Beneficiaries are directed to their handbooks or to www.triwest.com for information. The letter is primarily about the service request.

For further information, please contact your Local Network Representative. If you are not already registered for the secured Web site, please refer to www.triwest.com/provider to register. You can get immediate status on referral/authorization requests that you submit or for which you are the servicing provider via our secured Web site.