Share Referrals and Auths
Save to Folder
Which health Plans Require a Referral?
Tricare Prime, TPR, TPRO, TPO
Which health plans do not require a referral?
Tricare Select and all other PPo type plans
Scenario: An ADSM does not get a referral, do they have to pay for that appointment out of pocket?
Yes
Scenerio: An ADFM does not get a referral, do they have to pay for that appointment out of pocket?
Point Of Service
Which two tools do we use to check on someone's authorization?
Salesforce First, CareRadius Second
Which tool do we use to determine if something requires an Authorization?
RADS
What type of training does Line Of Duty apply to?
Active Duty Training, Inactive Duty Training, Drill Weekend, Any other training while on 30 days or less orders
Which Article in Knowledge base goes over LOD Claim inquiries?
1236
What is Continuity of Care?
allowing the patient to have an ongoing relationship with their provider despite changes
Which Article in the Knowledge Base goes over helping providers with an auth/referral in Availity?
1327
Which FAQ document helps with the path to walk a bene to a referral or auth in their Bene portal?
1092
Who handles LOD and some Tricare Prime Remote claims or auths?
DHA-GL (Defense Health Agency - Great Lakes)
Does an ADSM require an Authorization for Urgent care?
yes. They have the Nurse Advice line or the emergency room if it is 'urgent', otherwise they must wait for auth.
How do TRICARE referrals and authorizations work with OHI?
Must follow the rules of the OHI first then filter down to TRICARE
How long is an EOC timeframe for am ADSM?
6 months
How long is an EOC timeframe for anyone Other than an ADSM?
365 days
