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Similar to TRICARE Prime, TPR and TPRADFM beneficiaries choose a PCM to provide primary care services and coordinate specialty care. In some cases, however, TPR and TPRADFM beneficiaries may have to choose a non-network TRICARE-authorized provider as their PCM if there are no network providers in their area. These beneficiaries can also receive services from military providers, if they are willing to travel to the MTF.
ADSMs can receive primary care services without a referral, prior authorization, or fitness-for-duty review. Specialty and inpatient care will require a referral and prior authorization from Humana Military and the service point of contact (SPOC). The SPOC will determine if the specialty care should be referred to a military physician for a fitness-for-duty determination or to a TRICARE-authorized provider.
ADSMs assigned to a civilian PCM require a PCM referral for behavioral health care. ADSMs without an assigned PCM will need to contact ValueOptions at 1-800-700-8646 for behavioral health care. Providers fax Outpatient Treatment Reports (OTRs) for additional outpatient visits to ValueOptions at 1-866-811-4422. Clinical information is entered into the authorization system, and this information is electronically forwarded to the Military Medical Support Office (MMSO), who reviews each TPR request for services before an authorization number is given to the PCM or ADSM (for the behavioral health provider).
Family members using TPRADFM may require a referral for specialty care and/or prior authorization for certain services. Contact Humana Military at 1-800-444-5445 for more information or assistance.
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