Active Duty Servicemember, TRICARE Prime (HNFS) — Non-Network provider requesting Single Case Agreement

Active duty servicemember with Tricare Prime.

I received authorization for surgical procedures to treat lipedema. Since this a unique case, I requested to use a specific surgeon who has experience treating the disease. The surgeon is non-network. I have researched extensively and haven't found any network surgeons who have experience treating it.

The authorization is approved, but the provider is telling me that since Tricare does not do Single Case Agreements, "there's nothing they can do."

I've talked to numerous people at HNFS who have walked me through the process, and assured me that since I have an authorization, the surgeon only needs to bill Tricare directly for the approved codes. The codes are all listed on the document, and the end paragraph states that they are reimbursed in accordance with the TriCare Reimbursement manual.

I'm not an insurance expert, so I don't understand why this is halting the process. I dont understand what the Single Case Agreement will provide that has not already been explicitly approved. I have a case manager, but she does not deal with billing. Is there any other way I can escalate this somehow? Or was the provider "wrong" in being listed as a participating non-network provider since they won't honor the agreement?

If I don't receive treatment I'll likely be medically separated since I can no longer stay within body composition standards and the progressing pain is inhibiting my ability to perform duty-related tasks. I appreciate any insight anyone can give me.

submitted by /u/Admirable_Junket_411
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