Tricare to Allow Patients in Tricare West Region to Receive Specialty Care Without Preapproval

Yahoo

29-01-2025

The Defense Health Agency has suspended a requirement for Tricare Prime patients in the West Region to get pre-authorization from their Tricare contract manager for specialty care.
Defense Department health program officials announced Monday that the beneficiaries still are required to get a referral before seeking specialty care, but pre-authorization from TriWest Healthcare Alliance, the company that manages the Tricare program in the western U.S., will not be required through March 31.
The process is retroactive to Jan. 1.
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The waiver announcement is directly tied to problems with TriWest's referral portal that have affected processing, said Jacob Sanchez, referral management subject-matter expert for Tricare at the DHA.
"If you have Tricare Prime and are in the West Region, this waiver will allow you to access specialty services without interruption to your care," Sanchez said in an announcement of the change.
TriWest was awarded the contract to manage the Tricare West Region in late 2022 and began efforts to assume the contract in earnest last February after a federal court ruled it had rightfully won its bid.
Issues with the transition began to emerge in December when participating providers began voicing concerns that they had not received communications from TriWest on joining its network.
Then, customers who were required to update their payment information with TriWest found themselves unable to do so because of troubles with TriWest's online portal and call center.
Patients have written Military.com saying that they have experienced lost referrals; been referred to the wrong type of doctor -- for example, a brain surgeon when a spine surgeon was needed; and endured delayed or canceled referrals.
"These are not just administrative failures -- they are directly impacting military readiness and the well-being of those who serve," wrote an Air Force airman. "This is a national problem affecting thousands of service members and their families, and yet it seems to be slipping under the radar."
According to the waiver announcement, Tricare Prime enrollees may receive care from any Tricare-authorized specialist if they have a copy of an unexpired referral authorized by Humana Military or Health Net Federal Services before Jan. 1 or a referral dated Jan. 1 through March 31 from their primary care provider; and a copy of the waiver letter, which can be found on the Tricare West Region website.
The announcement also allows Prime patients in the region to see both network and non-network providers, as long as they are authorized by Tricare. They can ask the providers directly whether they are Tricare-authorized.
The waiver does not apply to: inpatient care; applied behavior analysis or other services under Tricare's Autism Care Demonstration; laboratory developed tests; or service under the Extended Care Health Option program.
Those services still will require pre-authorization, according to the announcement.
Tricare officials said that, beginning April 1, beneficiaries who see a non-network provider will start paying point-of-service fees, and they will be required to get preapproval from TriWest for any specialty care they were referred to by their primary care physician.
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