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As an active duty service member, you’ll find that you need authorization more often than your family members. While they need authorization only for those services specified by TRICARE, you must have MTF or SPOC authorization for most inpatient and outpatient specialty services from a civilian network or non-network provider.

Additionally, you need authorization for all maternity care, physical therapy, mental health services, family counseling and smoking cessation programs, even if that care is received from a military treatment facility (MTF).

If you are enrolled to an MTF and your primary care manager (PCM) refers you to a specialist outside of the MTF, your PCM must obtain an authorization from the medical management office of the MTF before you obtain the specialty care. If that authorization is not obtained, you may be held financially responsible for the claims for that treatment.

If you are not enrolled to an MTF or if you do not have a civilian PCM assigned, you or your provider must contact Humana Military at 1-800-444-5445 for authorization to see the specialist. Humana Military will notify you or your provider promptly regarding all requests for specialty care authorization.

Remember, TRICARE Prime or TRICARE Prime Remote enrollment is mandatory for all active duty service members, but it is not automatic, no matter where you are permanently assigned (near an MTF or in a remote area). If you live or work within the catchment (50 miles) of an MTF, enrollment to and utilization of that MTF is required.

If you are enrolled in TRICARE Prime Remote, your specialty care requests must be referred by Humana Military to your Service Point of Contact (SPOC)—a designated military health care specialist, located at the Military Medical Support Office. The SPOC will review all requests for specialty care to determine if your health care requires a “Fitness for Duty” determination.

If the SPOC determines that your condition may change your fitness for military duty status or may require a medical board review, you will be referred to the closest MTF with the capability to provide the care and make a duty determination.

If the SPOC determines that your fitness for duty is not in question, then you can be referred to a civilian specialist for the care. As a rule, maternity care will be provided locally. The SPOC will provide a reply to Humana Military within two working days of its receipt of a request. If your provider determines that you need urgent or emergency care, no authorization is necessary; however, Humana Military must be notified within 24 hours of seeking that care. Your commander may also request a military medical evaluation, at any time, and at his or her discretion.

If you or your provider do not receive authorization within six days, contact Humana Military before calling the SPOC.

You may always choose to obtain your specialty care in an MTF if that is your preference and your commander concurs. Let Humana Military know if you want to go to an MTF when calling for the authorization. They can help you to obtain an appointment.

It is extremely important that you understand the authorization process and follow the rules outlined in the TRICARE Prime Handbook and the TRICARE Prime Remote Handbook.

If you or your provider do not obtain authorization when required, if your care exceeds the scope of an approved authorization, or if you obtain care that is not a covered benefit without the approval of the MTF or SPOC, you may be held financially responsible for the entire bill for those health care services.

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Last Reviewed:  December 4, 2007