WE HEARD YOU: We’ve simplified in-network referrals.

NEW: Notification to US Family Health Plan of IN-NETWORK Specialty Referrals No Longer Required

NEW REFERRAL GUIDELINE EFFECTIVE:

• In-Network Specialty Care Referrals
  • New: Referrals submitted to the Plan are no longer required. Although not required, we do encourage submission to the Plan through the ProAuth system to enhance care coordination among providers and the Plan.
  • No Change: PCPs or referring specialists are responsible for sending specialty care referrals directly to in-network specialists and providing copies to your patients.
• Out-of-Network Specialty Care
  • No Change: All requests for medically necessary services that cannot be provided within our network must be submitted to the Plan via our ProAuth system and must be preauthorized by the Plan. Without preauthorization, the claim will process at the Point-of-Service benefit level and the patients will incur substantially higher out-of-pocket costs, including a $300 individual deductible and 50% coinsurance.

General Reminder: Patient Encounter Record Requirements

As a network provider you are required to submit patient encounter reports to referring providers when treating US Family Health Plan beneficiaries. TRICARE calls these “Clear and Legible Reports” (CLR). These must include specialty care consultation reports, care notes, operative reports, and discharge summaries.

Documentation should include the reason for the encounter, relevant history, and examination findings. It should also include a review of lab results, imaging reports, and any other relevant services provided.

Training and Support

For help using the ProAuth system or to schedule a personalized virtual training session, please contact [email protected].

For additional information please also visit https://martinspoint.org/For-Providers/Tools/USFHP-Referral-Program.

Thank you for your dedication to providing the best care for your patients/our members.