Amid continuing problems with the transition to a new West Region contractor, Tricare officials have temporarily suspended a rule requiring policyholders to get their referrals to specialists approved — essentially allowing Tricare West Prime beneficiaries to bypass that contractor, TriWest, in order to get specialty care.
The waiver process allows beneficiaries to take their referral from a primary care manager directly to their specialist without waiting for approval from TriWest. It’s in place through March 31 and is retroactive to Jan. 1, the start of the new contract and transition to TriWest Healthcare Alliance in the West region. Beneficiaries and medical providers alike have experienced a number of problems during the transition prompting lawmakers to seek answers.
“TriWest’s referrals portal has experienced issues that have affected the processing of new referrals,” said Jacob Sanchez, referral management subject matter expert for the Tricare Health Plan at Defense Health Agency, in the announcement of the waiver. “If you have Tricare Prime and are in the West region, this waiver will allow you to access specialty services without interruption to your care.”
Beneficiaries must still get referrals from their primary care manager. In addition, TriWest will accept all referrals and authorizations approved by the previous contractor — Health Net Federal Services or Humana Military — that are dated before Jan. 1. TriWest will accept those until the referral expires or until June 30, whichever comes first.
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Meanwhile, some beneficiaries have told Military Times their specialists can’t get access to their approvals in the TriWest system. Information was not immediately available about what action beneficiaries should take if their referrals dated before Jan. 1 were lost in the system. Some are being told to go back to that primary care manager for another referral.
“This specialty care referral waiver is really just a partial fix. It fixes things for those with a primary care manager” who can get an appointment with that PCM, said Karen Ruedisueli, director of government relations for health affairs for the nonprofit Military Officers Association of America. “But if you’re someone in the West region who lost your primary care manager as a result of this transition and you’ve been assigned somebody new and can’t get a new patient appointment for the next seven weeks ... it doesn’t really help you if you don’t have access to a PCM.”
This waiver allows people to see non-network providers, Ruedisueli said. It also allows TriWest more time to build up their network of medical providers, and it gives beneficiaries until April to find another provider if needed.
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With the new contract, six states were moved to West region coverage from the East region, bringing the total to 26 states. Here’s what Tricare beneficiaries in the West need to know about the temporary suspension of the requirement for TriWest to approve referrals, according to officials:
- They can continue to see their primary care manager to get referrals for specialty care, even if their PCM is not currently in TriWest’s network.
- They don’t have to wait for TriWest to process the approval to seek specialty care, and they should ask the PCM for a copy of the referral.
- They should ask the PCM to recommend a local Tricare-authorized specialist. They can also see a specialist they’ve gone to before, if that specialist is Tricare-authorized. “Tricare-authorized” means the provider is licensed by a state, accredited by a national organization or meets other standards of the medical community, and is certified to provide benefits under Tricare.
- The specialist doesn’t have to be in the Tricare network, but beneficiaries should ask the specialist if they’re Tricare-authorized before getting care.
- If the Tricare provider is no longer a Tricare network provider in the West region (or hasn’t been approved by TriWest), beneficiaries can still keep seeing them and pay Tricare Prime copayments. However, the provider must be Tricare-authorized.
- Beginning April 1, for future services, if the provider is still a non-network provider and isn’t named on the pre-authorization, the beneficiary will have to pay point-of-service fees. Also beginning April 1, beneficiaries will need a referral from their primary care manager that is approved by TriWest before seeing a specialist.
There are some exclusions to the waiver, such as Applied Behavior Analysis and Autism Care Demonstration, as well as Extended Care Health Option services, which affects those who depend on home health services for medically fragile children.
“It’s interesting that they purposely excluded a very disabled portion of the military community,” said Dr. Kristi Cabiao, CEO and president of Mission Alpha Advocacy, an organization that works to improve quality of life for military families within the Exceptional Family Member Program.
The waiver also excludes inpatient care and laboratory developed tests.
The broad issues surrounding the recent Tricare contract changes include problems with payments, authorizations and referrals and errors in provider and beneficiary information, Cabiao said.
Families have reached out to Military Times about a plethora of issues with TriWest, which are exacerbated by ongoing problems with reaching the contractor through their web portal or call center.
Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book "A Battle Plan for Supporting Military Families." She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.
