Out-of-Network Requests for TRICARE Prime Beneficiaries

TRICARE Prime, TRICARE Prime Remote active duty family members and TRICARE Young Adult Prime beneficiaries must see network providers to avoid additional out-of-pocket costs. TRICARE Prime beneficiaries (excluding active duty service members) who receive care from a non-network provider without a prior authorization or referral from Health Net Federal Services, LLC (HNFS) will be subject to paying Point of Service charges. If a non-network provider is requested for a TRICARE Prime beneficiary and there are network providers available within access standards, then care may automatically be redirected to a network provider. Please search our Network Provider Directory for assistance in finding a network provider. When requesting services, you may leave the name of the servicing provider blank and indicate only a specialty or service. HNFS will then assign a network provider. 

In the rare case that network providers are not available or there is a clinically significant reason care must be provided by a non-network provider, clear and detailed documentation must be provided for consideration of this request. The documentation should include answers to the following questions:

• Is the request due to a beneficiary preference or is it based on medical need?
• Has the beneficiary seen other specialists who cannot manage his or her condition? If so, please provide consultation reports.
• Have all available network providers been ruled out? If so, which network providers have been contacted?
• What is unique about the patient's condition and/or the provider's credentials that requires him or her to see a non-network specialist?