How to avoidReferral/Prior Authorization Request Delays or rejection

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.

•     When using the fax process, send only one completed TRICARE Patient Referral/ Authorization Form per fax. Sending multiple requests under one fax cover sheet increases the processing time.

•     Approved referrals are faxed to provider offices between midnight and 3:00 a.m. daily. It is important to leave (secure) fax machines on after hours to ensure prompt receipt of authorizations from TriWest. You may also obtain the status of services for which you are the approved servicing provider 24 hours a day,
seven days a week online if you are registered with www.triwest.com/provider.

•     Remember to submit the CPT or Healthcare Common Procedure Coding System (HCPCS) codes for services requested. “Episodes of care” (EOC) have been developed for common types of health care service requests that have also
been identified as having potential for claims processing errors. Experience shows that additional services are commonly requested, subsequent to the initial request. In such cases, more services may be approved than requested; providers should only provide medically necessary services.