JANUARY 27, 2025 – Are you enrolled in TRICARE Prime? You should know that the Defense Health Agency has waived the requirement to obtain pre-authorization for referrals to outpatient specialty care for TRICARE Prime enrollees in the West region. This means TRICARE-authorized specialty care providers don’t need to wait for TriWest to approve referrals issued by your primary care manager before providing outpatient care. However, you’ll still need to get a referral from your Primary Care Manager before getting that specialty care.
This process will be in place through March 31 and is retroactive to January 1, 2025.
“TriWest’s referrals portal has experienced issues that have affected the processing of new referrals,” explained Jacob Sanchez, referral management subject matter expert, TRICARE Health Plan, 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.”
This waiver doesn’t apply to:
- Inpatient care
- Applied behavior analysis or Autism Care Demonstration services
- Laboratory developed tests
- Extended Care Health Option services
If you need any of these four services above, TriWest will still need to pre-authorize your referral before you see your specialist.
Getting outpatient specialty care during the waiver period
During this waiver period, you should follow the rules of your TRICARE Prime plan, as described in the TRICARE Choices in the United States Handbook. You can continue seeing your PCM to get referrals for specialty care—even if your PCM is not currently in TriWest’s network.
So, what’s different?
Through March 31, you don’t have to wait for TriWest to process your referral to seek care. You should ask your PCM for a copy of your referral.
You can ask your PCM to recommend a local TRICARE-authorized specialist. You can also see a specialist you’ve seen before, if they’re a TRICARE-authorized provider. You can also search TriWest’s provider directory to find specialists in your area.
When you see your specialist, bring the copy of your referral, dated Jan. 1 through March 31. You can also bring a copy of the TRICARE West Region Referral Approval Waiver Letter, available on www.tricare.mil/west.
Note: If you see a civilian PCM, they may also be able to send your referral to your specialist electronically. But you should request and keep a copy for your records.
The process for getting specialty care within a military hospital or clinic hasn’t changed.
Not sure if your PCM or specialist is in the TRICARE network? If your provider is no longer a TRICARE network provider, you can keep seeing them and pay TRICARE Prime copayments. However, they must be TRICARE-authorized. This means they’re:
- Licensed by a state, accredited by national organization, or meet other standards of the medical community
- Certified to provide benefits under TRICARE
They don’t have to be in the TRICARE network but make sure to ask the provider if they’re TRICARE-authorized before getting care.
Starting April 1, if the provider is still a non-network provider and isn’t named on your pre-authorization, you’ll need to pay point-of-service fees.
Starting April 1, you’ll need a referral from your PCM approved by TriWest to see a specialist.
Referrals and authorizations issued before Jan. 1, 2025
Do you have an unexpired referral or authorization dated before Jan. 1, 2025? TriWest will accept all unexpired referrals and authorizations approved by the previous contractor (Humana Military or HNFS). These will be accepted through their expiration date, or June 30, 2025, whichever comes first. Your PCM doesn’t need to take additional action to get these approved again.
Do you have questions about referrals, authorizations, or other parts of the West Region transition? Check out TRICARE West Region Transition to learn whom to contact with your questions.
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Courtesy Story
Defense Health Agency