Provider Handbook
    

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TRICARE
Program
Options
       
TRICARE Prime
Eligibility for TRICARE Prime
TRICARE Prime Enrollment Card
Primary Care Manager

TRICARE’s family of programs offers comprehensive medical and dental benefits to every TRICARE beneficiary category. It is important to be aware of the choices available to beneficiaries.

TRICARE Prime
TRICARE Prime is a managed care option. TRICARE Prime enrollees receive most of their care from an assigned primary care manager (PCM) at a military treatment facility (MTF), if available, or from the TRICARE network. The PCM provides and coordinates care, maintains patient health records, and refers patients to specialists, if necessary. Specialty care referred by the PCM must be arranged and approved by Humana Military Healthcare Services, Inc., (Humana Military). Primary, routine, and preventive care are provided by the assigned PCM unless the PCM issues a referral.


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Eligibility for TRICARE Prime

TRICARE Prime is available to active duty service members (ADSMs) and their families, retired service members and their families, eligible former spouses, and survivors under age 65, as well as individuals 65 years of age or older who are not entitled to premium-free Medicare Part A. Beneficiaries who are not entitled to premium-free Medicare Part A must get a Notice of Award/Notice of Disapproved Claim which states that they are not entitled to premium-free Medicare Part A, in order for DEERS to be updated to reflect their continued entitlement to TRICARE.

National Guard and Reserve members and their families may be eligible for TRICARE Prime if the National Guard and Reserve member is:
 
  • Called or ordered to active duty for more than 30 consecutive days
  • Eligible for pre-mobilization benefits up to 90 days prior to their report date
  • Eligible for post-mobilization benefits under the Transitional Assistance Management Program (TAMP)


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TRICARE Prime Enrollment Card
Beneficiaries enrolled in TRICARE Prime receive TRICARE Prime enrollment cards. These cards are not required to obtain care, but do contain important information for the beneficiary. Figure 4.1 shows an example of the TRICARE Prime enrollment card.

TRICARE Prime Enrollment Card

Fig. 4.1

Image of TRICARE Prime Enrollment Card


In addition to their TRICARE Prime enrollment card, TRICARE Prime beneficiaries should present their uniformed services identification card or Common Access Card (CAC) at the time of service. Only the uniformed services ID card or CAC may be used to verify eligibility for care. Providers must verify eligibility by selecting “Online Provider Services” or by calling Humana Military at 1-800-444-5445 . Eligibility is also verified as part of the prior authorization process. See the TRICARE Eligibility section for more information about verifying eligibility.


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Primary Care Manager
TRICARE Prime enrollees are assigned a PCM who provides and coordinates care, maintains patient health records, and refers patients to specialists, if necessary. According to TRICARE, a PCM who is practicing within the governing state’s rules and regulations may be a provider of primary care services when rendering services within a TRICARE Prime service area location. This includes these PCM types:
 
  • Internal medicine physicians
  • Family practitioners
  • Pediatricians
  • General practitioners
  • Obstetricians/Gynecologists
A TRICARE Prime beneficiary relies on his or her PCM for referrals to specialty care providers and services either at an MTF or within the local network. For these services to be covered by TRICARE, the network PCM must submit a referral request. There is no requirement for a PCM referral and/or authorization for the following services:
 
  • Those provided by the selected, assigned, or “On Call” PCM in his or her office
  • The first eight visits for outpatient behavioral health services provided by a network provider in a fiscal year (October 1–September 30).* After the initial eight “unmanaged visits,” medical necessity reviews are required.
  • Emergency care
  • Clinical preventive services from a TRICARE network provider*
  • Services received while the beneficiary was using the point-of-service option
* Excludes ADSMs, who always require a referral or authorization.

See the Important Provider Information section for descriptions of specific PCM roles and responsibilities.

TRICARE Prime beneficiaries may be reimbursed for reasonable travel expenses for medically necessary care if a health care finder (HCF) authorizes a referral to a specialist who is located more than 100 miles away from their PCM’s office. TRICARE Prime enrollees are required to obtain all care from their PCM unless referred to another TRICARE-authorized provider. Beneficiaries will be referred to a TRICARE network provider based upon availability per the TRICARE access standards. A referral to a non-network TRICARE-authorized provider will only occur if a TRICARE network provider is unavailable.

ValueOptions will issue behavioral health referrals on a case-by-case basis. Refer to the Health Care Management and Administration section for more information about referrals and authorizations.  For specific inpatient cost-shares, contact Humana Military at 1-800-444-5445 or visit the TRICARE Web site.

TRICARE Prime Point of Service Option
A TRICARE Prime beneficiary who utilizes the point of service (POS) option may self-refer to any TRICARE-authorized (network or non-network) provider for medical or surgical services without a referral from his or her PCM. For behavioral health services, the POS option applies when the TRICARE Prime beneficiary receives nonemergency services from a non-network provider. Although a referral is not required when using the POS option, certain prior authorization requirements still apply. The beneficiary will pay a deductible and 50 percent of the TRICARE allowable charge. There is no catastrophic cap protection when using the POS option. Special considerations apply if the beneficiary has other health insurance. It is important to note the provider’s reimbursement remains unchanged, but the beneficiary will pay a larger portion of the total TRICARE-allowable charge. Also, it is important for providers to note the end date of referrals and to advise beneficiaries when additional referrals are required.


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Last Update: July, 2007