A prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care. Prior authorization is required for certain types of care and must be obtained before services are rendered.
Your PCM will request prior authorization from your regional contractor when required. If the service is authorized, Humana Military will give your PCM an authorization number along with specific instructions. For example, prior authorizations for medical or surgical services will have a begin date and end date. Prior authorizations for behavioral health services will specify a number of visits as well as a begin date and end date. You must receive care under the authorization before it expires. If not, you will need to get another referral and authorization from your PCM.
Services Requiring Prior Authorization
Active duty service members require prior authorization for all inpatient and outpatient specialty services. An additional fitness-for-duty review is required for maternity care, physical therapy, mental/behavioral health services, family counseling, and smoking cessation programs.
For all other TRICARE Prime enrollees, the following services require prior authorization in all three TRICARE regions:
Adjunctive dental services
Home health services
Hospice care
Nonemergency inpatient admissions for substance-use disorders or behavioral health
Outpatient behavioral health care beyond the eighth visit
Transplants—all solid organ and stem cell
TRICARE Extended Care Health Option services
Humana Military has additional prior authorization requirements. Browse the Humana Military web site or call 1-800-444-5445 to learn about Humana Military's requirements, as they may change periodically.
Getting a Second Opinion
You have every right to request a consultation with another provider for a second medical opinion when the initial provider is uncertain about a contemplated course of action. You, your PCM, or your regional contractor may request a second medical opinion. If you wish to seek a second opinion, go to your PCM and explain your situation and any questions you may have about the first specialist’s suggested care. Then, ask your PCM to coordinate a referral to another specialist and request a referral from Humana Military if necessary.
Point of Service Option
The TRICARE Prime point of service (POS) option gives you the freedom to seek and receive nonemergency health care services from any TRICARE-authorized provider without requesting a referral from your PCM for additional costs. See the TRICARE: Summary of Beneficiary Costs flyer for details about POS fees.
The POS Option does not apply to the following:
Active Duty Service Members
Newborns or adopted children in their first 60 days
Emergency Care
Preventive care services from a network provider
First eight behavioral health outpatient visits from a network provider
