Prime Remote Handbook

Active duty service members require a referral for any specialty care. Before seeing a specialist, you will need a referral from your PCM or primary care provider and Humana Military. Network PCMs will coordinate specialty care referrals with Humana Military for you. If you don’t have an assigned network PCM, you or your primary care provider must coordinate with Humana Military for specialty care referrals. In either case, Humana Military will contact you or your PCM or primary care provider regarding all referral requests. Refer to Humana Military’s Web site or call the toll-free number to learn about region-specific referral requirements and details about obtaining referrals.

All specialty care requests for TPR-enrolled active duty service members are then referred from Humana Military to your service point of contact (SPOC). The SPOC will review all requests and determine if your health care requires a fitness-for-duty determination.
             

• If the SPOC thinks that your condition may change your fitness-for-duty or that your condition requires a medical board, they will refer you to the closest MTF that has the ability to provide the care and make a duty determination.
• If the SPOC thinks there is no impact on your fitness-for-duty, they will refer you to a civilian specialist for the care. As a rule, maternity care will be provided locally. The SPOC will provide an answer to Humana Military within two working days of the request, or sooner for an urgent problem.
• Your commander also may request a military medical evaluation at his or her discretion.
• You may choose to obtain your specialty care in an MTF at any time if that is your preference and your commander concurs. Inform Humana Military when coordinating your referral.
• You cannot refer yourself to a military or civilian specialist. If you seek nonemergency care from other sources without first contacting your PCM or primary care provider and Humana Military, you may be held financially responsible for the entire bill for those health care services.

Before seeing a specialist, you will need a referral from your PCM or primary care provider. A referral from Humana Military may also be required. Network PCMs will coordinate specialty care referrals with your regional contractor for you. If you do not have an assigned network PCM, you or your primary care provider must coordinate with Humana Military for specialty care referrals. Refer to Humana Military’s Web site or call the toll-free number to learn about region-specific referral requirements and for details about obtaining referrals.

If you seek nonemergency care from other sources without first contacting your PCM or Humana Military, you will be getting care under the POS option, resulting in higher out-of-pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer  to learn about POS fees.

Family members enrolled in TPRADFM who are referred by their PCM for specialty care at a location more than 100 miles (one way) from the PCM’s office may be eligible to have reasonable travel expenses reimbursed by TRICARE. Reasonable travel expenses are the actual costs incurred while traveling, including meals, gas/oil, tolls, parking, and tickets for public transportation (i.e., airplane, train, bus, etc.). You must submit receipts for expenses above $75.

TRICARE will use government rates to estimate the reasonable cost. You are expected to use the least costly mode of transportation. TRICARE will reimburse the actual costs of lodging (including taxes and tips) and the actual cost of meals (including taxes and tips, but excluding alcoholic beverages) up to the government rate for the area concerned.

In some cases, a non-medical attendant may also be authorized for travel reimbursement. The non-medical attendant must be a parent, guardian, or another adult family member 21 years of age or older.

To qualify, you must have a valid referral and travel orders from a TRICARE representative from the TRICARE Regional Office (TRO). You should obtain the travel orders before traveling. Contact your TRO travel representative if you think you may qualify for this travel reimbursement.

       
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Figure 3.1

       
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