Off-post specialist referral being declined

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Grimszr

Well-Known Member
PEB Forum Veteran
Registered Member
Good morning. I was recently diagnosed with ulcerative colitis at a hospital off post and the gastroenterologist on base won’t approve tricares referral request for me to continue seeing the dr. I want to see. Is there any way to get around the on post dr and get that approval ?
Thank you.
 
Grimszr said:
Good morning. I was recently diagnosed with ulcerative colitis at a hospital off post and the gastroenterologist on base won’t approve tricares referral request for me to continue seeing the dr. I want to see. Is there any way to get around the on post dr and get that approval ?
Thank you.
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Probably because there is the specialist on base. Tricare shouldn’t have to pay for a referral in the network if the services are on base.
 
Gizzy said:
Probably because there is the specialist on base. Tricare shouldn’t have to pay for a referral in the network if the services are on base.
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Very true. Although tricare case managers have called supporting going off post. only person stopping that from happening is the on post gastro.
 
Grimszr said:
Very true. Although tricare case managers have called supporting going off post. only person stopping that from happening is the on post gastro.
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Here is what you can do, I work in an MTF and manage referrals. Go to the patient advocate, tell them you are requesting a second opinion and are wishing to be seen off base GI. Squeaky wheel gets greased. Also, a referral can come from your PCM for GI.
 
Gizzy said:
Here is what you can do, I work in an MTF and manage referrals. Go to the patient advocate, tell them you are requesting a second opinion and are wishing to be seen off base GI. Squeaky wheel gets greased. Also, a referral can come from your PCM for GI.
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strangely the patients advocates told me they could not go around the on-post gi and could not help. And I was told by the on post Primary case manager that the PA could not approve it only gi could.
I wouldn’t normally feel so strongly about going off post if it wasn’t the case that the on post gastro missed the diagnosis a year ago and said I was fine when it turned out I had a chronic condition. Left me having no trust with them to do their job or to have my best interest in mind.
 
Try this: call the appointment line at your base. Tell them you “See GI at xyz GI for ulcerative colitis I need a referral renewal for more visits.” Nurses place the referrals most time the providers aren’t even aware and it should slip through and get approved by tricare and once it’s approved there’s nothing the PCM and GI can do
 
Another option, go to ER, say I was diagnosed with UC and I’m in a lot of pain. ER will put it in your visit notes the diagnosis just more Dr opinions
 
Yes I have all the off post records documented through the medical records office on base and the on-post GI stated on the phone that he did not trust civilian doctors and wanted to redo the procedures and biopsies that have already been done. After the off-post gi has given me steroids and other non long term medication to help me recover from the flare up. So he will see somewhat normal conditions when redoing a procedure on me and I worry they will downplay the severity.
 
Gizzy said:
Try this: call the appointment line at your base. Tell them you “See GI at xyz GI for ulcerative colitis I need a referral renewal for more visits.” Nurses place the referrals most time the providers aren’t even aware and it should slip through and get approved by tricare and once it’s approved there’s nothing the PCM and GI can do
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Tried this and the nurses push the referral to the GI each time. Thanks for all these tips though I appreciate the help.
 
Not given yet. Was part of a tentative plan with the off-post GI to start that process with our next appointment at the end of may.
 
Sorry I did not clarify originally. I never had a referral I was admitted to the hospital in Austin and on the 3rd day of me being there I was diagnosed and made an appointment with the off-post GI before I was discharged. So was paid for by tricare due to it initially being an ER visit. This was my 4th ER visit in 2 months.
1st ER being on base but not tested/screened at all for UC.
 
Grimszr said:
Sorry I did not clarify originally. I never had a referral I was admitted to the hospital in Austin and on the 3rd day of me being there I was diagnosed and made an appointment with the off-post GI before I was discharged. So was paid for by tricare due to it initially being an ER visit. This was my 4th ER visit in 2 months.
1st ER being on base but not tested/screened at all for UC.
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It’s okay:) I see. Hmmmm. Seems need to go above the patient advocate. You could change your PCM or request an appointment for “abdominal pain” with another on post pcm. Another option, you can file a IG case, show them the supporting documentation. That will stir the pot and you’re in post GI will just give up. Can notify them you went through pt advocate.


Does TRICARE cover second opinions? | TRICARE

FAQ about second opinion
tricare.mil tricare.mil
 
Gizzy said:
It’s okay:) I see. Hmmmm. Seems need to go above the patient advocate. You could change your PCM or request an appointment for “abdominal pain” with another on post pcm. Another option, you can file a IG case, show them the supporting documentation. That will stir the pot and you’re in post GI will just give up. Can notify them you went through pt advocate.


Does TRICARE cover second opinions? | TRICARE

FAQ about second opinion
tricare.mil tricare.mil
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I called IG and they said my only option was to file a case against the GI himself. Is that what you’re referring to?
And I will look into mentioning this to my PCM at our next appointment. I was told he could not approve the referral by the case manager but I’ll ask him personally.
 
Grimszr said:
I called IG and they said my only option was to file a case against the GI himself. Is that what you’re referring to?
And I will look into mentioning this to my PCM at our next appointment. I was told he could not approve the referral by the case manager but I’ll ask him personally.
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Also thank you for the link.
 
Grimszr said:
I called IG and they said my only option was to file a case against the GI himself. Is that what you’re referring to?
And I will look into mentioning this to my PCM at our next appointment. I was told he could not approve the referral by the case manager but I’ll ask him personally.
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That’s an option, but, you can always force the hand and keep going to the ER, don’t you have follow ups with your PCM after each visit to ER?
 
Gizzy said:
That’s an option, but, you can always force the hand and keep going to the ER, don’t you have follow ups with your PCM after each visit to ER?
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Conveniently my PCM had a week off when I got back so I have to wait till June 19th for his next appointment. I might be able to call the case manager and force an earlier date considering I just left the hospital.
 
Call her, or the appt line maybe first, tell the appointment line your symptoms are getting worse and you need a sooner appt w pcm or a different pcm
 
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