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Referrals and Prior Authorizations:
What Are They and When Are They Needed?
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While TRICARE Standard does not require referrals, some services may require prior authorization.
What Is a Referral?
A referral is a recommendation from your health care provider to see another provider (a specialist) because the referring provider is not qualified to provide the needed service or it is outside his or her scope of practice. With TRICARE Standard, you may see any TRICARE-authorized provider at any time for routine, urgent, emergency or specialty care without a referral from your family doctor.
What is Prior Authorization?
Prior authorization is the process of reviewing a service or procedure to determine whether it is medically necessary at the level of care requested. Your provider will need to contact Humana Military to obtain prior authorization for you. You can visit the prior authorization list to find out if prior authorization is required.
Here are some examples of services that require prior authorization in every TRICARE region:
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Adjunctive dental services
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Home health services
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Hospice care
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Nonemergency inpatient behavioral health care, including nonemergency inpatient admissions for substance use disorders
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Outpatient behavioral health care after the eighth visit in a fiscal year (Oct. 1–Sept. 30)
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Transplants (solid organ and stem cell)
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TRICARE Extended Care Health Option (ECHO) services
Once an authorization is granted, the contractor will issue service beginning and ending dates for medical or surgical services. For behavioral health care authorizations, the contractor will also specify a certain number of visits. All authorized care must be received before the authorization’s end date. If not, your provider must obtain a new authorization.
Additional authorization rules may apply, so it is best to contact Humana Military if you have questions. |
