No Referrals Needed for West Region Prime Users Thanks to Backlog

A medical assistant checks a patient’s temperature during a hospital visit. (U.S. Navy/Jacob Sippel)
A medical assistant checks a patient’s temperature during a hospital visit. (U.S. Navy/Jacob Sippel)

Tricare Prime users in the West region who need civilian specialty care won't need an official Tricare referral through March 18, Tricare officials said, thanks to problems stemming from a series of changes rolled out Jan. 1.

Typically, Tricare Prime users must get a referral authorization from Tricare to receive speciality care.

But a Jan. 1 hand-off from United Healthcare, the West region's previous contractor, to Health Net has resulted in a major referral backlog caused, in part, by problems with the provider network, Tricare and Health Net officials said. Many beneficiaries have complained, and doctors who had been in-network before the change were no longer listed as Prime network providers.

"[From] now through March 18, the Defense Health Agency is allowing Health Net Federal Services to waive its usual authorization process for Tricare Prime referrals in the West Region," Tricare said in a release. "Tricare West users should download a referral and authorization waiver letter, then seek Tricare outpatient covered service specialty care."

The waiver is in place only for the Tricare West region, not for the newly formed East region, managed by Humana, Tricare officials confirmed. Prior authorization is still required for inpatient care, autism applied behavior analysis therapy, laboratory developed tests and Extended Health Care Option (ECHO) services.

Users who have enrolled in Tricare Prime in the West region since December may also be caught up in an enrollment backlog that has blocked them from being assigned a primary care provider, officials said. Those beneficiaries can see any primary care provider in or out of network without paying any point of services charges until March 31, Tricare officials said.

Officials warned Health Net is also still experiencing "extremely high call volumes" as a result of the problems.

"The Defense Health Agency recognizes the issues with backlogs, call wait times and the number of provider choices for beneficiaries in the West Region. We are committed to working with Health Net Federal Service to resolve them in a timely manner," said Ken Cannestrini, acting director of Tricare Health Plan said in a release.

The contractor and region change are among a series of other sweeping reforms to Tricare cost shares and fees that hit Jan. 1, and a series of pharmacy fee increases that hit Feb. 1.

-- Contact Amy Bushatz at Follow her on Twitter at @amybushatz.

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