For correct TRICARE beneficiary care coordination and appropriate claims payment, it is important to
understand the difference between a referral and prior authorization and the requirements and processes for each.
When Is a Referral Needed?
When a beneficiary requires medical or surgical services that are beyond your scope of practice, you must request a referral from Humana Military Healthcare Services, Inc. (Humana Military). A TRICARE Prime beneficiary must first seek care from his or her primary care manager (PCM) or the military treatment facility (MTF). Humana Military will approve a referral for specialized medical services from a civilian professional or ancillary provider
only if the services are not available from the PCM or MTF. The MTF is always the primary source of care and has the “right of first refusal.”
Exceptions to the referral requirement for TRICARE Prime beneficiaries are emergency care, preventive care services from network providers, the initial eight outpatient behavioral health care visits per fiscal year* or when using the point of service (POS) option.
Note: Referrals and authorizations for care are not required for active duty family members enrolled in an overseas TRICARE Prime option, including TRICARE Global Remote Overseas, when they are traveling in the United States, and POS fees do not apply. The exception is for nonemergency inpatient behavioral health care; authorization is required and POS fees will apply if it is not obtained.
When Is Prior Authorization Needed?
Prior authorization is issued for requested services, procedures or admissions that require medical necessity review before services are rendered.
Prior authorization must be obtained before services are rendered. Prior authorization may be required for various services and care, including adjunctive dental care, hospice and psychiatric services.
To determine if prior authorization is needed for your patient, refer to Humana Military’s prior authorization list, available in the
MyHMHS for Providers section of the site.
Note: Active duty service members require prior authorization for all inpatient and outpatient services from civilian providers, except in an emergency.
How Do I Request Referrals and Prior Authorizations?
Referrals and prior authorizations may be requested in one of two ways:
Note: For urgent referral requests, call 1-800-444-5445. For behavioral health care referrals and prior authorizations, contact ValueOptions, Inc. at 1-800-700-8646.
Referral authorization will be based on whether or not the referral is for a TRICARE-covered service. Once the requested services have been authorized, Humana Military will notify you, the referred provider and the beneficiary of the number of approved visits and the time frame in which the visits must be completed. If the beneficiary requires additional services beyond the scope of the referral, they must
be approved through you.
Humana Military will also send autofax confirmations to providers once referrals and prior authorizations are approved.
Note: Prior authorizations are based on medical necessity and are not a guarantee of payment. Provider payment penalties may be applied if you fail to obtain prior authorization or the services provided exceed the scope of an approved referral/authorization.
To learn more about referrals and authorizations in the TRICARE South Region, refer to your
TRICARE Provider Handbook. The Web site will provide the latest updates.
* There are certain providers, however, for which physician supervision and a referral are always required; these include licensed professional counselors, licensed mental health counselors and pastoral counselors.
Back to Top
