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Help with at homebirth Tri-care California

post #1 of 4
Thread Starter 

I am currently 5 months pregnant. I have had a hell of time. TRICARE WEST PRIME does not know its own policies. I just moved here and things are difficult. Tricare prime covers at home births with a CNM which in Monterey their are 5 all of which are willing to accept Tricare. By their policies they should in theory cover them. Well here is the catch or the problem I am running into they are not listed as a preferred provider. When I went into my local office in Seaside (once Fort Ord) the manager knew nothing about having an at home birth. When I call I get the run around I found out that I need  to submit an authorization for a non-preferred provider since the closest preferred provider is 2 hours away. Now before I could do that I needed to get a referral from my new local PCM for a midwife. Which I did and they in return gave me a midwife in San Fransisco. What do I do? How do I get an authorization for a local non preferred CNM. The latest attempt I made the supervisor told me that it can not be done that I needed to switch to Standard. However the midwifes here told they have got 100% payment through Prime and I have meet 2 of the women that have done it but they said that it was not this hard as the previous in office supervisor did it for them. She has since PCS to another duty station and the new one who is 3 months old does not even know how to look up referrals she had to call the 1800 # to find out about my referral. She is dumber than the people she manages. The guy under her who has been there for 5 years says the other gal knew how to do it but he did not. That it was possible. He suggested going to IG or the Post Commander. I dont want to do that but I will.

 

HELP? SUGGESTIONS?

post #2 of 4
Thread Starter 

post #3 of 4

Did you get anywhere with this?

 

I am currently in the same boat. I have tricare prime remote. There are no in-network CNM's that do HB. So I found an CNM out-of network and got a referral to her from my PCM. They said that they couldn't find the CNM in their system and if I wanted to see her I would have to go to her as a POS care provider meaning I would have to pay a 300 copay and 50% of charges. But I am not sure if that number is only their allowable charges or what she actually charges.

 

I am really confused as to why they originally told me I would be okay as long as I got a referral and now I am being told I have to do POS care! If you found anything let me know. 

post #4 of 4
Are you sure they mean a preferred provider and not a certified provider? A preferred provider is in-network and accepts TC payments where a certified provider is just a hcp in good standing in the state. They do have to apply/send in some info to become certified but that shouldn't be difficult as long as they are licensed.

If you can't get a referral or authorization or whatever it's called (sorry, I've only ever had Standard so don't know all the official terms for that sort of thing with Prime), you can use the POS (point-of-service) option. You will have a deductible and copay just like with Standard but it's higher. Where Standard is either $50 or $150 deductible and a 20% copay, the Prime POS is $300 deductible and 50% copay.

The issue with being Prime and trying to get a referral may be that TC is not required to give you a referral or authorization for a homebirth MW just because you ask if they have another provider (CNM or OB) who can provide you with adequate care, even if it is in a hospital. If they don't give you a referral, you can appeal but I don't know how all of that works.
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