TRICARE Referrals and Authorizations

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, we also evaluate medical and behavioral health care trends.

Beneficiaries may be directed to receive care at a military treatment facility (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 provider in our network.

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.

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MTF Optimization/KSA Referrals

Military hospitals and clinics, generally known as military treatment facilities (MTF), 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 prior to 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 the referral or refuse it.

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 provider online submission tool, to include appropriate clinical information (specific link to be updated prior to start of health care delivery).

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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 requirements for appeals.

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 urgency of the situation. 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 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 (specific link to be updated prior to start of health care delivery).

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