Learn the Basics About Referrals and Pre-Authorizations (West Region)

This article contains information specific to beneficiaries living in the West RegionAlaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excludes Rock Island arsenal area), Kansas, Minnesota, Missouri (except St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (southwestern corner including El Paso), Utah, Washington and Wyoming.. Check the map to find your region.

“Referral” and “pre-authorization” are two common health care terms. What is the difference between the two? You need referrals for services that aren’t primary care if you’re enrolled in the TRICARE Prime option. For example, you may need a referral to see a cardiologist. Getting pre-authorization means getting the care approved by Health Net Federal Services, LLC (HNFS) before going to an appointment for care. For example, if a cardiac surgeon needs to perform heart surgery, you may need a pre-authorization.

Here are a few important things to remember about the two terms:

• Even if you don’t need a referral, you may still need a pre-authorization for some services.
• When your primary care manager (PCM) submits a referral for specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide., he or she may refer you to a specialist at a military hospital or clinic, if one is available. This is true even if you have a civilian PCM.
• Otherwise, your PCM will refer you to a TRICARE network provider, when available.
• Except active duty service members (ADSMs), TRICARE Prime beneficiaries may use the point-of-service option. This option allows you to self-refer to any TRICARE network or non-network provider. You’ll have to pay higher out-of-pocket costs. You’ll also be responsible for the total cost of the services provided if seeing a non-network provider for a non-covered service.

How do you know if you need a referral or a pre-authorization to receive care? That depends on your TRICARE health plan option. For example, ADSMs need a referral for any care their PCM doesn’t provide. These include urgent, routine, preventive, and specialty care. Active duty family members enrolled in TRICARE Prime need referrals for most, but not all, services that their PCM doesn’t provide. Those enrolled in other plans don’t need a referral for any type of care, except Applied Behavior Analysis, which is offered through the Comprehensive Autism Care Demonstration.

Not sure whether you need a referral or pre-authorization? Remember to use the HNFS online tool to help you verify requirements before you get care. You don’t want to get stuck paying out of pocket for services that require approval.

You should allow about three business days for HNFS to process your referral. It may take less time if your PCM determines your referral to be “clinically urgent.” You can check your referral status by logging in to your secure account. You can also call HNFS’ customer service line. And you can view and download determination letters using the secure beneficiary portal.

To learn more about the referral and pre-authorization process, you can check out Authorizations and Referrals.