Provider Handbook

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When a TRICARE Prime beneficiary’s primary care manager (PCM) is unable to provide a specialized medical service, the PCM must contact Humana Military to request a referral. Humana Military issues a referral when a TRICARE Prime beneficiary needs specialized medical services from a civilian professional or ancillary provider only if services are not available at the military treatment facility (MTF) or at the PCM’s office. The MTF is always the primary source of care for TRICARE beneficiaries. The MTF has the “right of first refusal” to provide care for a TRICARE beneficiary.

Referral requests may be submitted online via the “Provider Resources/Online Provider Services” feature If you are unable to submit your request online, information related to other avenues for submission may be obtained by calling the Humana Military TRICARE Service Line at 1-800-444-5445 during normal business hours.

Note: ADFMs enrolled in Prime options overseas, including TGRO, do not require a referral and authorization for care when traveling in the United States, and point of service fees do not apply to them.

• All referrals must be made to network providers. Network providers are listed in the “Provider Resources/Find a Provider” feature. (Select “Find A Provider” under the Provider Resources section.)
    
  
  • Submit a referral on the Web site, via fax, or over the phone.
     
  • The quickest way to submit referral information is online via the “Provider Resources/Online Provider Services /Referrals and Authorizations” feature. Web site referral services have been automated, and in many cases provide immediate response and confirmation.
     
  • Another quick method is to call 1-800-444-5445, select option 3, and enter the request through the Interactive Voice Response System (IVR).
     
  • You may also fax the Patient Referral Authorization Form (PRAF). The Humana Military PRAF fax number is 1-877-548-1547.
     
  • If you are having trouble with the Web or fax, call the Humana Military TRICARE Service Line: 1-800-444-5445. However, you may incur wait time.
     
• For behavioral health referrals, contact ValueOptions at 1-800-700-8646.
   
• When completing the referral, always have the beneficiary sponsor’s Social Security number (SSN), diagnosis, and clinical data explaining the reason for the referral.
   
• Check referrals via the Humana Military Web site. To check the referral status by phone, call Humana Military’s TRICARE Service Line at 1-800-444-5445 and select the option, “To check the status of an authorization or previously requested service.”
   
• The health care finder (HCF) will send the referral by AutoFax to the PCM and the referred provider when the care is authorized. Authorization is based on whether or not the referral is for a covered service.
   
• For urgent referrals, call 1-800-444-5445 or fax the PRAF to 1-877-548-1547.
   
• The referral will clearly specify the services authorized, the number of visits, and the timeframe in which the visits must be completed.
   
• If services are needed beyond the scope of the referral, additional services must be approved through the PCM.
   
• Humana Military will notify the beneficiaries of an approved referral.

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