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Prior Authorization, Referral and Benefit Tool

The tool allows you to easily determine HNFS approval requirements.

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Requirements (Referrals vs. Prior Authorizations)
 

Referrals

Referrals are for services that are not considered primary care. For example, a primary care manager (PCM) sends a patient to a cardiologist to evaluate a possible heart problem.

HNFS referral types:

Evaluation only – Allows for two office visits with the specialist to evaluate the beneficiary and perform diagnostic services, but not treat. This type of referral includes diagnostic/ancillary services that do not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and one follow up visit for that established patient.)

Evaluation and treatment – Allows for one evaluation visit with the specialist and five follow-up visits. This type of referral includes subsequent care (diagnostic and ancillary services, related procedures) that does not require HNFS approval. (The referral will include an evaluation code and a consultation code for the servicing provider to determine which level of care is required, and five follow up visits for that established patient.)

Procedure only – Allows for the test/procedure only.

Second opinion – Allows for one evaluation visit with the specialist and one follow-up visit.


Important things to remember about referrals:

  • Providers can visit our Episode of Care page for examples that can help you understand referrals and when to submit a new request to HNFS. 
  • Beneficiaries may be directed to receive care at a military hospital or clinic
  • TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must see TRICARE network providers when available. If a non-network provider is requested for a TRICARE Prime beneficiary and there are network providers available within access standards, then care may automatically be redirected to a network provider. 
  • The Point of Service (POS) option allows TRICARE Prime beneficiaries (excluding active duty service members) to see any TRICARE network or non-network provider without referrals from their PCMs or HNFS. 


Prior Authorizations

Prior authorizations for certain services and/or procedures require Health Net Federal Services, LLC (HNFS) review and approval, prior to being provided. Check to see if we offer a Letter of Attestation you can attach instead of clinical documentation. This will expedite the review process.

Note: Please review our Supplemental Health Care Program page for information on the active duty service member approval process.

Network and non-network providers who submit claims for services without obtaining the required prior authorization will receive a 10 percent payment reduction during claims processing.