Provider Handbook

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TRICARE has added a health care provider category to its roster of authorized TRICARE provider types. The Corporate Services Provider Class consists of institutional-based or freestanding corporations and foundations that render professional, ambulatory, or in-home care and technical diagnostic procedures. Some of the specific types of providers who fall within this category may include:
 

• Cardiac catheterization clinics
• Comprehensive Outpatient Rehabilitation Facilities (CORFs)
• Diabetic outpatient self-management education programs (ADA accreditation)
• Freestanding bone marrow transplant centers
• Freestanding kidney dialysis centers
• Freestanding magnetic resonance imaging (MRI) centers

• Freestanding sleep disorder diagnostic centers
• Home Health Agencies (HHAs) (Pediatric or Maternity Management)
• Home infusion (ACHC accreditation)
• Independent physiological laboratories
• Radiation therapy programs

Network corporate services providers are certified during the credentialing process. Contact Humana Military at 1-800-444-5445 for more information.

Each non-network corporate services provider applicant must complete a TRICARE Application for Provider Status to become a TRICARE-authorized provider. Qualified non-network providers can find the Corporate Services Provider Application at the MyTRICARE Web site. For corporate services provider conditions for coverage and reimbursement of services, refer to the TRICARE Policy Manual, Chapter 11, Section 12.1 on the TRICARE Web site.

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A military treatment facility MTF is a military hospital or clinic on or near a military base. The contracted provider network augments the resources available in the MTF.

Network providers may work closely with MTF providers near them. For an accurate, up-to-date listing of the MTFs in the South Region, visit the Humana Military Web site or visit the MTF Locator.

MTFs are given the “right of first refusal” for TRICARE Prime beneficiaries residing in a Prime Service Area (PSA) of an MTF for referrals for inpatient admissions, specialty appointments, and procedures requiring written prior authorization, providing that the MTF has capability to render the service requested by a civilian provider. This means that TRICARE Prime beneficiaries must first try to obtain these services at the MTF. The MTF staff will review the referral for the right of first refusal to determine if they have the specialty capability and an available specialty care appointment within the access standards. If the service is not available at the MTF within the appropriate access standards, then the beneficiary is referred to a TRICARE network provider.

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Providers will be reported to the Department of Veterans Affairs (VA) and to the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA) as a TRICARE network provider. The VA has the right to directly contact the provider and request care on a case-by-case basis for VA patients or CHAMPVA beneficiaries if the provider is available. The provider is not required to meet access standards for CHAMPVA beneficiaries but is encouraged to do so. The provider rates applicable to the provider’s TRICARE contract do not apply to VA referrals and the provider is free to negotiate with the VA. CHAMPVA beneficiaries are not to receive preferential appointment scheduling over a TRICARE beneficiary.

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Humana Military and its subcontractors ensure that physicians, licensed independent practitioners, facilities and other health care professionals within the TRICARE network meet credentialing criteria. Adherence to credentialing criteria that meets or exceeds requirements of the DoD ensures a quality health care delivery system for TRICARE.

Once approved for participation, each provider is monitored for quality of care and adherence to DoD and Humana Military standards. Humana Military uses several methods to monitor quality, including:
      

• Complaints and grievances
• Focused clinical quality and preventive health studies

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