Supplemental Health Care Program

The Supplemental Health Care Program (SHCP) provides coverage by civilian health care providers to eligible individuals. Although authorizations and claims processing are administered by the TRICARE contractors, it is funded separately by the Department of Defense (DOD) and follows different rules than TRICARE.

Eligible Individuals

• ADSMs
• National Guard and Reserve members on active duty
• National Guard and Reserve members authorized for line of duty (LOD) care
• National Oceanic and Atmospheric Administration personnel, U.S. Public Health Service personnel, and Reserve Officer Training Core (ROTC) students, cadets and midshipmen
• eligible foreign military personnel (for outpatient care only)
• TRICARE-enrolled designees
• any non-TRICARE eligible person who receives approval from a military hospital or clinic to receive civilian services under SHCP (those with Medicare are not eligible for SHCP except if they are inpatient at a military hospital or clinic, and while remaining inpatient at the military hospital or clinic, require civilian diagnostic services that cannot be performed at the military hospital or clinic)
• beneficiaries on the Temporary Disability Retirement List are eligible to obtain required periodic physical examinations through SHCP
• medically retired former members of the armed services enrolled in the Federal Recovery Coordination Program

Authorization Process

• A civilian or military hospital or clinic provider submits a request to Health Net Federal Services, LLC (HNFS) for review.
• Health Net Federal Services reviews the request for TRICARE coverage. Please refer to our Checking the Status of a Prior Authorization or Referral page for processing timeline and notification guidelines.
  
• Health Net Federal Services will deny requests for services not covered by TRICARE unless:
  • A Defense Health Agency (DHA) waiver approval is present (see Authorization Denials below) or
    
  • The medical condition is exempt from the DHA waiver process.
  Note: In some cases, HNFS must request additional information in order to determine if the requested services meet TRICARE benefit coverage criteria. This additional information must be submitted to HNFS by the date indicated in the Additional Information Request Letter or the authorization request will be cancelled. It is extremely important providers respond to these information requests in a timely manner, especially for services requested on an urgent basis.

  Authorization Denials

  1. ADSMs receiving a denial letter for non-covered services will be given instructions that a waiver from DHA is required.
     
     • ADSMs, not TRICARE Prime Remote (TPR), should coordinate the waiver with their military hospital or clinic of enrollment.
       
     • TPR service members will contact their Uniformed Services Headquarters point of contact (POC)/Service Project Officer for waiver consideration. This is not the same as the Specified Authorization Staff at DHA-Great Lakes (DHA-GL). The denial letter contains this contact information. If the episode of care related to the denied service is being managed by a military hospital or clinic, then the TPR ADSM should coordinate the waiver with the military hospital or clinic managing the episode of care.
  2. Once the waiver is requested, the director of the DHA will review.
     • Beneficiaries should follow up with their military hospital or clinic (non-TPR) or Uniformed Services Headquarters POC/Service Project Officer (TPR ADSM) for status checks of any waiver requests that are submitted. The contact information is included in the denial letter.
  3. If the waiver is approved by the DHA, the requested services will be approved by HNFS.
     
  4. ADSMs may receive a denial letter for covered services requested in the civilian network environment if HNFS is directed by the military hospital or clinic or DHA to deny the request (for example, the military hospital or clinic or DHA is requiring care be performed within the direct care system or there are fitness for duty concerns). In these instances, the denial letter from HNFS will include instructions for the ADSM to contact the military hospital or clinic or DHA-GL for any appeal considerations.

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