Patients who use Tricare Prime in the West Region will not need to get preauthorization for most specialty care from their Tricare contract manager until June 30, extending a previous deadline, the Defense Health Agency announced last week.
Defense officials said April 30 that they have extended the referral approval waiver through the end of June to ensure that patients continue having access to care following the change in Tricare contract managers Jan. 1.
The extension marks the second time that DHA has suspended the requirement for Tricare patients to get preauthorization for specialty care from TriWest Healthcare Alliance, the region’s contract manager, as a result of problems patients have had getting appointments and care.
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The decision to extend the approval waiver was made following an assessment of the “current state of referrals,” according to Richard Hart, the division chief for health plan design at the Defense Health Agency.
“This waiver extension will ensure that West Region beneficiaries can continue getting specialty care without interruption to their care,” Hart said in a statement.
Since the new Tricare contract went into effect on Jan. 1, hundreds of family members and providers have reported problems with claims processing, appointments, access to care and payments.
Kimberly Yazell, a patient in Missouri, is among the dozens who have written to Military.com about delays in care and spending hours on the phone trying to reach TriWest to solve problems accessing treatment.
Yazell said a planned surgery was delayed because providers were dropped from the network following the TriWest changeover and she was told she had to start the approval process over to get care.
“It’s all very disorganized,” Yazell said. “My doctor’s office randomly got an authorization, so I thought, ‘OK, this is positive. I’m going to have my surgery’ … but my primary-care doctor is no longer in-network, so what happens after?”
Dozens of providers also reported delays in payments or not receiving reimbursement for claims.
Candice Mullendore, an occupational therapist in Papillion, Nebraska, said her office has had nearly 3,000 appointments for Tricare patients since the beginning of the year but has experienced significant issues with collecting the $900,000 owed to her providers.
“Military families deserve uninterrupted access to critical health care services, and providers cannot sustain operations under these conditions indefinitely,” Mullendore said in an email.
The approval extension is just one of several deadline extensions granted to Tricare beneficiaries in the West Region since the start of the new contract. The Defense Health Agency has repeatedly extended the deadline for patients to update their payment information to TriWest and also to receive care from a non-network provider without incurring point-of-service fees.
According to the Defense Health Agency, under the extension, patients still must go to their primary-care manager to receive a referral for specialty care, even if their primary-care provider is not in TriWest’s network.
As part of the announcement on the preauthorization waiver extension, the Defense Department also said it has extended the point-of-service fee waiver for non-network providers until Sept. 30.
The waiver extension does not apply to certain types of care or patients at some military hospitals and clinics, according to the Defense Health Agency.
The waiver does not apply to inpatient care; applied behavior analysis or other services under Tricare’s Autism Care Demonstration; laboratory developed tests; or service under the Extended Care Health Option program.
It also does not apply to beneficiaries whose primary-care managers are located at the following military treatment facilities in:
Defense Health Agency officials reminded patients that their specialty-care provider must be a Tricare authorized provider.
Patients can ask the providers directly whether they are authorized for Tricare, according to the Defense Department.
Related: Tricare Patients Fear Losing Preferred Health Care Providers Amid Contract Transition
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