If you are using tricare select, you dont typically need a referral for routine or specialty care, but there are. A well designed tricare west referral authorization template can help people to. A list of indicators used by the cqm department is attached for your use. How to submit an authorization or referral request tricare west. Visit our requesting prior authorization and referral changes page for details. Dd 28761, tricare prime enrollment, disenrollment, and. To download an enrollment form, rightclick and select to saveas or download direct from the whs forms page. This form must be filled out by you the parent or legal guardian in order to have your child placed in a residential treatment center. Statement of personal injury possible third party liability. Careaffiliate requires login, web authorizationreferral form warf. Fax the application to health net federal services, llc at 18448189289. This includes urgent, routine, preventive, and specialty care services. For enrollment, use your regionspecific dd3043 form.
Your pcm works with your regional contractor for the referral and authorization. All other beneficiaries enrolled in a tricare prime plan. Tricare humana military referral authorization form nashville. Tricare operations manual, chapter 18, allows coverage for laboratory developed tests ldts when specific coverage criteria are met. Use the prior authorization, referral and benefit tool to find out if a service requires a health net referral or prior authorization. Health net federal services will look at the request once we receive both your.
Referrals and authorization active duty service members. If youre enrolled in a tricare prime plan, your primary care manager pcm will work with your regional contractor for the prior authorization. Prior authorization form tricare west ambry genetics. The portable device must have humidification and battery capability. Tricare east providers can find behavioral health, certification, claim, pharmacy and other forms here. Referrals are required for most specialty care under tricare prime, while authorizations may be required for. Health net federal services is the managed care support contractor for the tricare north region.
You need a referral from your primary care manager pcm for any care heshe doesnt provide. Tricare prime remote, tricare reserve select fax 8663125831. Due to the covid19 outbreak, the military health system nurse advice line is experiencing a larger than usual call volume, and wait times are long. Requests for changes to inpatient authorizations can be made via fax using our inpatient tricare service request notification form. You can also have your doctor send the form for you. Tricare prime beneficiaries need to know about both referrals and authorizations. Use one of two online options to submit authorization and referral requests to health net. Uhcmilitarywest fill online, printable, fillable, blank pdffiller. Warf tool request profile guide portable cpaps are only covered for deployed beneficiaries or those who travel on official business work three or more daysmonth. Provides the option to print and save a pdf with the content submitted. Initial request for applied behavior analysis referral for applied behavior analysis request for applied behavior analysis.