Authorizations and Referrals

Authorizations

Prior authorization for care may be required for a medical service or procedure that your provider recommends. Your provider will request prior authorization from TriWest. If the service is authorized, TriWest will give your provider an authorization number along with specific instructions and a begin date and end date for your authorization.

TRICARE beneficiaries in the West Region who are registered users of www.triwest.com can now receive notification of their authorization or referral as soon as it’s ready through a QuickAlert e-mail from TriWest Healthcare Alliance, instead of waiting for notice by mail. To protect your privacy, no personal information will be included in the e-mail—just a notice of an authorization status change and a link to the login page on www.triwest.com for more information.

You must receive care under the authorization before it expires. If you do not, you’ll need to obtain another authorization from your provider.

Prior authorization is required for all inpatient and outpatient specialty services, including but not limited to:

• Home health care
• Hospice
• Inpatient facilities, including all elective medical and surgical admissions
• Behavioral health sessions after eight visits
• Non-emergent transports and non-emergent ambulance
• Radiology
• Surgical procedures, including transplants (except corneal), and cosmetic procedures
• Physical, occupational or speech therapies
• Hearing aids
• Extended Care Health Option (ECHO) program

An additional fitness-for-duty review is required for maternity care, physical therapy, behavioral health services, family counseling and smoking cessation programs.

Services such as mammograms, annual pap smears, colonoscopies, cardiac stress tests, eye exams and many others do not require a prior authorization.

If you have questions regarding authorization requirements for a certain procedure or service, call TriWest at 1-888-TRIWEST (874-9378).

Referrals

Referrals are necessary when you need certain services or procedures that your Primary Care Manager or physician does not provide. Your physician will submit a referral to obtain services from a specialist and will coordinate the referral request with TriWest.

Except for emergencies, active duty service members must have a referral for all care obtained outside of a Military Treatment Facility. Referrals are required for most services for TRICARE Prime and TRICARE Prime Remote beneficiaries.

Just as with authorizations, registered users of www.triwest.com can opt to receive referral notices in their e-mail through TriWest’s QuickAlert service.