The following guidelines will help expedite your referral and
authorization requests:
• Submit an online request or, if that option is not
available to you, use the TRICARE Patient Referral/Authorization Form for any
TRICARE Prime beneficiary requiring a specialty care referral or a prior
authorization for any TRICARE West Region beneficiary who requires prior
authorization for services on the Prior Authorization List
Submit complete online referral and authorization
requests with physician documentation and all clinical indications, including
laboratory/ radiology results related to the requested service. Attach relevant
documentation to your online request. If you have an electronic medical
management system, you may also copy/paste from that system into your online
request. If you are unable to submit your requests online, submit a complete
and legible TRICARE
Patient Referral/Authorization Form by fax.
• If you submit referrals and authorizations online on a
regular basis, please use a Request Type profile that includes your requested
codes.
* TriWest has online user guides to help you select the correct Request Type
profile. TriWest has more than 100 profiles and using them will eliminate any
code range issues. If you cannot use a profile, TriWest limits code ranges (low
and high) to 10 codes. If the code range is more than 10 codes, the user will
get an error indicating that the “allowable” code range has been exceeded and
will have to put in a code range less than 10 codes. The user will not be able
to enter the request until there is an acceptable code range.
• Be specific about the requested services and provide
the most appropriate procedure and diagnosis codes. Requests for DME also
require complete information on applicable codes. A reasonable range is
acceptable.
Include National Drug Codes (NDCs) for medication requests.
• Make sure the correct ICD-9 and Current Procedural
Terminology (CPT®) code(s) are included. Include clinical documentation for
services on the Prior Authorization List.
Be sure to clearly reference your contact information, particularly the fax
number to which TriWest should respond. Incomplete
forms may slow the process.
• When pictures are needed to support the requested
service, the preferred method of submission is to use the online referral and
authorization tool
and attach a digital photograph to the request.
Pictures sent via fax do not transmit clearly and may delay the process while
TriWest requests and awaits receipt of originals.
• Generally, approvals are active for 180 days, unless
otherwise indicated on the referral/ authorization approval letter. If the
servicing provider is unable to provide the approved services prior to the
expiration of the referral,
a new referral/authorization request must be submitted. If it has been 180 days
or more since the initial approved request for the same diagnosis, the PCM
should request the new referral/authorization. If the specialist has obtained a
referral from the PCM within 180 days, the specialist may make the request
for services related to the same diagnosis.
If the servicing provider wishes to add additional procedural or treatment
codes to the approved referral or authorization, then a new referral/
authorization request must be submitted covering the additional requested
services.
• Verify the beneficiary’s demographic information
(sponsor’s Social Security number, address, date of birth, etc.) and include it
on the request form.
• When using the fax process, you only need to fax your
referral or authorization request once, if you have confirmed that you faxed
the referral
to the correct number and have a confirmation from your fax machine. Re-faxing
creates duplicate requests and delays processing. You may check the status of
your request online at any time if you are registered with
www.triwest.com/provider, regardless of whether the request was submitted
online or by fax. You may also call 1-888-TRIWEST (1-888-874-9378) if you have
not received a response within five days.
