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Referrals and Authorizations Health Net TRICARE North

Referral vs. Authorization. A referral is the process of sending a patient to another professional provider (physician or psychologist) for consultation or a health care service.An authorization is a process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care..

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Referrals and Authorizations Health Net TRICARE North

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    1. Referrals and Authorizations Health Net — TRICARE North 9 August 2007

    2. Referral vs. Authorization A referral is the process of sending a patient to another professional provider (physician or psychologist) for consultation or a health care service. An authorization is a process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care.

    3. Health Net Web Site Referral and Authorization

    4. Systems Used for Referrals and Authorization Referral Decision Tool Prior Authorization Determination Tool Online Authorization and Referral Submission Tool Fax Ad Hoc/Unique Identifier Number (UIN) — MTF Request/Notification Form — civilian Referral and Authorization Status Tool

    5. Right of First Refusal (ROFR) ROFR is defined as providing the MTF with an opportunity to review each request from a civilian provider to determine if the MTF has the capability and capacity to provide the treatment.   In TRICARE Prime Service Areas (PSA) that include an MTF, the MTF has the ROFR for all referral and authorization requests when the MTF has the capability and elects to participate. Defined in MTF MOU ROFR sent to the MTF closest to the benficiary's residence zip code

    6. Point of Service (POS) Allows TRICARE Prime or TPRADFM the freedom to obtain medically necessary TRICARE-covered services from any TRICARE-authorized provider without a referral POS is applied to TRICARE Prime beneficiary claims when: Network specialty services are not “authorized” by the PCM or Health Net Non-network specialty services are not “authorized” by Health Net — includes first eight outpatient behavioral health visits Specialty care services rendered by a network or non-network provider when services have been referred to an MTF

    7. Point of Service (POS) (cont’d) POS is applied to TPRADFM claims when: Non-network specialty services are not “authorized” by HN where network specialty providers are available — includes first eight outpatient behavioral health visits POS is applied to TRICARE Prime beneficiary and TPRADFM claims when: Prime/TPRADFM elects to remain in a non-network facility ER care which is clearly related to a routine illness Primary care is received from a provider other than the PCM (except preventive care)

    8. Point of Service (POS) Rules Document

    9. POS Cost-Share Reversal POS cost-share may be reversed if Health Net receives evidence from the beneficiary or provider that the PCM or other appropriate provider referred the beneficiary for care Acceptable evidence to reverse a POS cost-share: Referral on file Paper referral from PCM (MTF or civilian provider) Administrative error by Health Net or PGBA

    10. TRICARE Prime Remote TPR and TPRADFM referrals TPR ADSMs require a referral from the MTF or PCM for civilian specialty care TPR ADFM must coordinate their referrals through the PCM and network specialty care providers TPR and TPRADFM authorizations TPR ADSMs require prior authorization for all inpatient and outpatient specialty services Additional fitness-for-duty review determination by SPOC TPRADFM authorization requirements – Health Net Web site authorization tools

    11. Health Net Web Site Referral and Authorization

    12. Overseas Travel: Referrals, Authorizations and Urgent Care Seek all routine medical care before traveling Fill all prescription medications Locate an MTF near your overseas destination(s) Write down the contact info for the TAOs, US Embassies and MTFs in the areas traveling Take PCM’s and Health Net’s phone numbers Pay for care up front and file a claim for reimbursement

    13. Overseas Travel: Referrals, Authorizations and Urgent Care (cont’d) Urgent care — medically necessary treatment that is required for illness or injury that would not result in further disability or death if not treated immediately, but requires medical attention within 24 hours. Routine or urgent care requires a referral from the PCM Beneficiaries seeking urgent care should contact their PCMs prior to seeking care

    14. Overseas Travel: Referrals, Authorizations and Urgent Care (cont’d) Unable to contact PCM while traveling, contact PCM first business day after return from overseas. For assistance locating a provider while traveling overseas call: TRICARE Europe: 1-888-777-8343, Option 1 TRICARE Latin America and Canada: 1-888-777-8343, Option 3 TRICARE Pacific: 1-888-777-8343, Option 4 Seek care at an MTF whenever possible or contact an MTF patient liaison for assistance

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