TRICARE Referral and Pre-Authorization Basics (West Region)

This article contains information specific to beneficiaries living in the West Region. Check the map to find your region.

Do you know the difference between referrals and pre-authorizations? If you have TRICARE Prime, you need referrals for most care your primary care manager (PCM) doesn’t provide. In these cases, your PCM will refer you to another provider or specialist. Your PCM does this by submitting a referral request to your regional contractor. Health Net Federal Services, LLC (HNFS) is the regional contractor for the TRICARE West Region.

Similarly, if you use any TRICARE plan, you may need pre-authorizations from HNFS for certain services. This means that the regional contractor must approve certain types of care or procedures before you receive them. For example, if your PCM thinks you might have a heart issue, they’ll submit a referral for you to see a cardiologist. If the cardiologist decides you need heart surgery, they’ll submit a pre-authorization request to HNFS before performing surgery.

HNFS reviews these requests from your provider.

Keep these basics in mind:

• If you live near a military hospital or clinic, you may be referred to that facility for care, even if you have a civilian PCM.
• You can view authorization status and determination letters on HNFS’ secure portal. You’ll need to log in to see this information.
• You should schedule your appointment with the provider listed in the authorization letter. Be sure to schedule care before your authorization expires. Otherwise, you’ll need to get the care re-approved. If you need to change to a different network provider, you can use the “Change an Authorization” option in HNFS’ secure portal or contact HNFS.
• If you have TRICARE Prime and you aren’t an active duty service member, you have a point-of-service option. This lets you see any TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS without a referral. Keep in mind, you’ll have higher out-of-pocket costs with this option.
  

Do I need a referral or pre-authorization?

Whether you need a referral or pre-authorization depends on:

• Your TRICARE plan,
• Your beneficiary category, and
• The type of care you need.

Use HNFS’ Prior Authorization, Referral, and Benefit tool to check your plan’s requirements.

Sign up for status alerts

HNFS processes referrals and pre-authorizations within two to five business days. Referrals marked “urgent” or “emergent” are usually processed faster. You can sign up to receive texts or email alerts that let you know HNFS has processed a request. To do this, go to the “Manage Preferences” section of “My Account” in your HNFS secure portal.

 

Want to learn more?

Visit Referrals and Pre-Authorizations to learn more about using referrals and pre-authorizations with your TRICARE plan.