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TRICARE Prime:
Referrals and Authorizations and
MTF Right of First Refusal
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Referrals and Authorizations
Some services may be obtained without a PCM referral. These include clinical preventive services and behavioral health services; however, active duty service members will require a PCM referral for behavioral health services obtained in the civilian sector. When seeking clinical preventive services, you must use a network provider. There are times when you will need to see a specialist for a diagnosis or treatment that your PCM cannot provide. Your PCM will provide referrals to access services from specialty providers and will coordinate the referral request with Humana Military, when necessary.
If you live near an MTF and are referred for specialty care, inpatient admissions, or procedures requiring prior authorization, Humana Military will attempt to coordinate your care at the MTF first. When the services are not available at the MTF, the care will be coordinated with a TRICARE network provider.
Prior authorization is required for certain types of care and must be obtained before services are rendered. Your PCM will request prior authorization from Humana Military when required. If the service is authorized, Humana Military will give your PCM an authorization number along with specific instructions.
Active duty service members require prior authorization for all inpatient and outpatient specialty services. An additional fitness-for-duty review is required for maternity care, physical therapy, mental/behavioral health services, family counseling, and smoking cessation programs.
Humana Military has additional prior authorization requirements. Call 1-800-444-5445 to learn about Humana Military's requirements, as they may change periodically. |
MTF Right of First Refusal
If you live in a TRICARE Prime Service Area (PSA), it is important to remember that your local military treatment facility (MTF) is your first option for many health care services. If a civilian provider submits a request on your behalf, you may be referred instead to the MTF. If this has ever happened to you, it may be very confusing and frustrating to you and your family. Knowing why this happens and how the process works can make a world of difference.
The MTF has the right of first refusal (ROFR) for any services requested by a civilian provider, if the services are available at the MTF. If a TRICARE beneficiary living near an MTF is referred for specialty care by a civilian provider and the service is available at the MTF, the MTF may decide to provide the care. If services are refused by the MTF, the referral will be allowed with a network provider.
The MTF has the right of first refusal (ROFR) for any services requested by a civilian provider, if the services are available at the MTF. If a TRICARE beneficiary living near an MTF is referred for specialty care by a civilian provider and the service is available at the MTF, the MTF may decide to provide the care. If services are refused by the MTF, the referral may be allowed with a network provider.
How Does the Right of First Refusal (ROFR) Process Work?
When a request is submitted to HMHS from a civilian provider, if the specialized services you require are available at the MTF, your request will be sent to the MTF’s Point of Contact (POC) for review. The MTF will notify Humana Military in a very timely manner, usually within one business day for routine requests and within thirty minutes for urgent requests if they accept or refuse the care.
If your referral is accepted by the MTF, Humana Military will complete your referral to the MTF and the MTF will call you to schedule an appointment.
If the MTF refuses your referral, Humana Military will complete your referral to a network provider and you will receive notification so you may schedule your appointment.
The important points to remember are:
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An MTF has the first right of refusal for specialty care they can provide for Prime beneficiaries living with a 40 miles radius or 60 minute drive time of an MTF
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Referrals from your civilian provider may be sent to the MTF if the MTF has the service/care available
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MTFs may accept or refuse the referral
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If the MTF accepts, they may call you to schedule an appointment within the MTF
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If you live near an MTF, you should not schedule an appointment with a network provider until you receive your approval letter for network care.
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