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  Your Primer on TRICARE Prime in the South Region (Article 9)
 
As a TRICARE provider, it’s important that you understand TRICARE Prime so that you can deliver care optimally and even assist beneficiaries in making the right health care decisions. Humana Military offers the following five-point primer as a quick reference to this managed care option.

1. TRICARE Prime Eligibility. TRICARE Prime is available to:
  • Active duty service members, family members, survivors and eligible former spouses of active duty personnel
  • Retirees, their family members and survivors under age 65
  • Reserve Component members and their families if the sponsor is activated for more than 30 consecutive days
All eligible beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System. Providers can verify eligibility by calling Humana Military at 1-800-444-5445. You can also verify eligibility at time of service when beneficiaries present their TRICARE Prime enrollment and military ID cards.

2. Beneficiary Responsibilities. To access TRICARE Prime care, eligible beneficiaries must enroll. Active duty service members are automatically covered under the TRICARE Prime benefit, but still must enroll. There is no enrollment fee for active duty family members. Retirees and their family members must pay an annual enrollment fee of $230 for an individual or $460 for a family.

Active duty service members and their families are not responsible for any co-payments. There are exceptions: when using the TRICARE Prime point-of-service (POS) option or when filling prescriptions anywhere other than a military treatment facility (MTF) pharmacy.  Enrolled retirees and their families are responsible for copayments when seeking care from a network provider. The POS option also applies to retirees and their family members whenever they self-refer to a non-network provider for covered medical services (except for their first eight outpatient behavioral health visits).  Annual deductibles are not required of any TRICARE Prime beneficiaries, unless they use the POS option.

3. The Primary Care Manager. TRICARE Prime beneficiaries select or are assigned a primary care manager (PCM) when they enroll. A PCM can be either an MTF provider or a provider within the TRICARE network of civilian providers.

TRICARE Prime beneficiaries enrolled with an MTF PCM receive most of their care from an MTF, augmented by the civilian network. Specialty care must be arranged and approved by Humana Military to be covered under TRICARE Prime.  TRICARE Prime beneficiaries with a civilian PCM receive most of their care from the civilian PCM. This could include:
  • Internal medicine physicians
  • Family practitioners
  • Pediatricians
  • General practitioners
Civilian PCMs provide and coordinate care, maintain patient health records and refer patients to specialists.

4. Specialty Care Referrals. TRICARE Prime beneficiaries rely on PCMs for referrals to specialty care providers and services either at an MTF or within the civilian network. For these services to be covered by TRICARE, the network PCM must submit a referral request. Referrals or authorizations are not required for emergency care.

Local health care finders (HCFs) at TRICARE Service Centers (TSCs) can help you find specialty care after a referral is requested. When a network provider is unavailable, you may obtain a referral to a non-network provider on a case-by-case basis.  Humana Military network specialty providers must provide clearly legible, specialty care consultation and operative reports to referring providers within 10 working days of the patient’s date of service. Hospitals and other facilities must also send all discharge summaries or operative reports to referring providers within 10 working days of the patient’s date of service or discharge.

5. Point-of-Service Option. Under the POS option, TRICARE Prime beneficiaries may self-refer to any TRICARE certified (network or non-network) provider for medical or surgical services without a PCM referral.

For behavioral health services, the POS option applies when the TRICARE Prime beneficiary receives nonemergency services from a non-network provider.  Although a referral is not required when using the POS option, certain prior authorization requirements still apply. The beneficiary will pay a deductible ($300 individual and $600 family) and 50 percent of the TRICARE allowable charge. There is no catastrophic cap protection when using the POS option.

 
FAQs About Behavioral Health Care (Article 10)
The following are answers to the top questions behavioral health care providers have about caring for TRICARE patients.

Do TRICARE Prime patients require a referral for outpatient services?
No. TRICARE Prime beneficiaries can self-refer for eight unmanaged outpatient psychotherapy visits per fiscal year (Oct. 1–Sept. 30). Please note that Psychological Testing (CPT 96100–96117) is excluded and continues to require authorization.

How do I obtain a behavioral health authorization for a patient?
Network providers may call ValueOptions to obtain authorization for claims payment purposes. Additional visits beyond the initial eight can be requested via fax or mail using the Outpatient Treatment Report.

How can I obtain forms?
ValueOptions forms are located on the  Humana Military Web site.

Will I receive anything in writing stating the authorization parameters?
Yes. A letter will be faxed to your office stating the authorization number, begin and end dates, CPT codes and number of visits authorized. Please contact ValueOptions to ensure your correct fax number is on file.

Do psychiatric evaluations (90801) require a prior authorization?
Each provider is allowed one outpatient psychiatric interview session per beneficiary per year without authorization. If another is required, you must obtain prior authorization.

Is a physician referral required for Licensed Mental Health Counselors to provide TRICARE patient services?
Yes. TRICARE policy requires services rendered by LMHCs, Licensed Professional Counselors and Pastoral Counselors have a physician referral prior to the initial evaluation, as well as continued oversight throughout the course of therapy in order to be reimbursed by TRICARE. A Letter of Referral should be submitted with the claim to PGBA, LLC.

My request for behavioral health services was denied. Can I appeal?
Yes. A written request for reconsideration, along with a copy of the denial letter, the necessary components of the medical record and any supporting documentation should be mailed to ValueOptions. You will be notified of a decision within 30 days.

Have copayments changed for behavioral health services?
Yes. Copayments for Medication Management (CPT 90862), Psychiatric Evaluation (CPT 90801) and Psychological Testing (CPT 96100–96117) have a $12 copayment for TRICARE Prime retirees and their family members. Copayments for all other services remain unchanged.

Where do I send the consultation report?
Fax consultation reports to 1-877-850-9599. Receipt of the report is logged and matched with the appropriate authorization and then forwarded to the appropriate military treatment facility (MTF) PCM.

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