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Under all TRICARE programs, no referrals or authorizations are required for TRICARE beneficiaries receiving emergency care in or out of their TRICARE region. However, TRICARE Prime beneficiaries are instructed to contact their PCM or regional contractor (e.g., Humana Military, Health Net, or TriWest) within 24 hours of an inpatient admission or the next business day to coordinate ongoing care.
TRICARE Prime beneficiaries must receive a referral from their PCM or regional contractor for urgent care. If they do not receive a referral, the claim will be paid under the point of service (POS) option.
If you provide emergency or urgent care services to a TRICARE beneficiary from a different region, the beneficiary will be responsible for payment of the applicable cost-share, and you will submit reports and claims information to the region in which the TRICARE beneficiary resides (not the region in which they received care). See the Claims Processing and Billing Information section for more information.
Note: If the condition that prompted the emergency care is found to be routine and there is no evidence that the condition ever appeared to be anything other than routine, the care will be covered under the POS option for TRICARE Prime beneficiaries. Exceptions are made if the beneficiary was referred to the emergency department by his or her PCM or regional contractor.
If you have questions about processing claims for beneficiaries from other regions, contact Humana Military at 1-800-444-5445.
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