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Simplifying Referrals and Prior Authorizations (Article 4) |
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Know the What, When and How
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Providers continue to ask questions about referrals and prior authorizations. While both have specific steps, neither process needs to be too perplexing. Follow these simple guidelines to understand the “what, when and how” for obtaining referrals and prior authorizations.
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What... |
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A referral is the process by which a primary care manager (PCM) or other provider sends a TRICARE beneficiary to another professional or ancillary provider for specialized medical services.
A prior authorization is the process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care before the services are rendered.
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When... |
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Beneficiaries enrolled in TRICARE Prime must obtain a referral from their PCM before receiving any type of nonemergency care that the PCM cannot provide (e.g., specialty care, ancillary services, etc.). Beneficiaries using TRICARE Standard and TRICARE Extra do not require referrals for any type of care.
A prior authorization is required for all inpatient hospital admissions and certain outpatient procedures. For a complete list of services requiring prior authorization, refer to the chart in Section 7 of your TRICARE Provider Handbook or visit the “Provider Resources” section.
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How... |
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Referral and prior authorization requests may be made online, by faxing the Patient Referral and Authorization Form (PRAF) to Humana Military or by calling Humana Military. (For behavioral health referrals, contact ValueOptions.) Follow the simple steps below to submit referral or authorization requests. |
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Humana Military’s first priority is to provide the best quality health care to TRICARE beneficiaries. As a referring provider, it is your responsibility to decide which specialist best meets the needs of your patient. Understanding the differences between these specialties and conveying the distinctions to patients’ parents will help reduce confusion and provide a better understanding of how best to help their child.
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Online
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Fax
1-877-548-1547 |
Phone
1-800-444-5445 |
| After registering on the site, visit the “Provider Resources” section, click on “Online Provider Services,” then select “Referrals and Authorizations.” |
Fax the completed PRAF to Humana Military. Fax behavioral health referrals to 1-866-811-4422. |
If you are having trouble with the Web or fax, contact a health care finder during regular business hours. For behavioral health services, call 1-800-700-8646. |
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Quick Tips for Submitting Referrals and Authorizations (Article 5) |
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When submitting your requests follow these quick tips: |
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Referrals |
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- Referrals must be made to network providers. For beneficiaries enrolled in TRICARE Prime Remote for Active Duty Family Members, referrals may be made to non-network providers when a network provider is not available.
- For behavioral health referrals, contact ValueOptions at 1-800-700-8646.
- When completing the referral, always have the sponsor’s Social Security number (for the patient), the diagnosis and clinical data explaining the reason for the referral.
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Authorizations |
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Make sure you have the following information (if applicable) when submitting an authorization request: |
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- Sponsor’s Social Security number and address
- Patient’s name, date of birth and relationship to sponsor
- Admitting hospital, date, time, physician tax ID, name and billing address
- Clinical conditions for surgery, including CPT codes
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