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TRICARE Transition Challenges in the West Region

On Jan. 1, 2018, the Defense Health Agency (DHA) implemented a number of changes to TRICARE, including a region consolidation and health care policy changes mandated by Congress. Several customer service issues are now affecting TRICARE beneficiaries in the western U.S. including call center wait times, processing backlogs and a limited provider directory. The DHA is aware of these issues and is monitoring the regional contractor’s response to address these challenges.

"The DHA 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 Services to resolve them in a timely manner,” said Ken Canestrini, acting director of TRICARE Health Plan at DHA. "Service members, their families and others enrolled in TRICARE expect the high standard of service we set for our contracting partners."

The West Region’s contractor, Health Net Federal Services (HNFS) is addressing the following issues:

Referral Backlog: HNFS is experiencing a large backlog processing referrals and authorizations. Medically urgent requests get priority in processing. This backlog was caused by many issues, including duplicate and incomplete submissions from providers.

Defense Health Agency (DHA) is allowing HNFS to waive its usual authorization process for TRICARE Prime referrals in the West Region:

  • For care received from network providers, the referral authorization process is waived until April 15.
  • For care received in military hospitals and clinics, the referral authorization process is waived until March 31.

This means that if you get a referral during the waiver period, you can download a referral and authorization waiver letter, then seek TRICARE outpatient covered service specialty care. Prior authorization is still required for inpatient, applied behavior analysis (ABA), laboratory developed test (LDT) and Extended Health Care Option (ECHO) services.

West Region beneficiaries referred to a specialty care provider by their primary care manager (PCM) between now and April 15 for network PCMs, or March 31 for military PCMs, should ensure their PCM provides them with a TRICARE West Region Referral/Authorization Waiver Approval Letter.

If you have received a referral on or after Jan. 1 from your PCM for specialty care but have not received an authorization from HNFS, then you should present your referral for specialty care and TRICARE West Region Referral/Authorization Waiver Approval Letter to a TRICARE-authorized provider to get TRICARE-covered specialty care services. As always, the DHA recommends using a TRICARE network provider to reduce or eliminate copayments and out-of-pocket costs.

Additionally, HNFS is working to process all requests within TRICARE standards by extending operating hours and adding additional staff. Simplified TRICARE urgent care guidelines allow most beneficiaries to seek urgent care without a referral or visit limits.

Call Center Wait Times: HNFS is experiencing extremely high call volumes. They are currently working to meet the increased demand by hiring additional temporary staff and cross-training. In the meantime, self-service options are available at www.tricare-west.com.

Enrollment Backlog: During the system-wide, three-week enrollment freeze in December 2017, enrollments were received but couldn’t be processed. HNFS is now processing the backlogged enrollments in addition to the January enrollments. Beneficiaries enrolled in TRICARE Prime whose primary care manager (PCM) isn’t in the HNFS network or who haven’t yet been assigned a PCM can see any TRICARE-authorized PCM through June 30, 2018 and Point of Service charges won’t apply. Beneficiaries enrolled in TRICARE Select can see any network or non-network TRICARE-authorized provider. Out-of-pocket costs will vary based on the provider’s network status. Beneficiaries may check their current status on milConnect or register at www.tricare-west.com for additional self-service options.

Expanded Provider Network and Delivery: HNFS is working to improve the completeness and accuracy of the HNFS provider directory. While TRICARE contractors consistently update their information, the provider directories are dependent upon network providers and facilities to provide accurate information and to update that information whenever there are changes.

The DHA is focused on making sure beneficiaries receive the excellent health care and stellar customer service they deserve. Visit www.tricare.mil/changes to learn more about the changes to TRICARE.

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