From time to time, TRICARE Prime beneficiaries may require services that are beyond the scope of your practice or specialty area as their primary care manager (PCM). Any service that is not considered “primary” and cannot be performed by a general internist, general pediatrician or family physician, warrants a referral.
In these instances, you will need to contact Humana Military Healthcare Services, Inc. (Humana Military) to generate a referral for your patient to see another provider for a consultation or service that you believe is necessary but are not prepared or qualified to provide. Humana Military will issue an authorization based on a PCM referral when a TRICARE Prime beneficiary is in need of specialized medical services from a civilian professional or ancillary provider and the services are not available at the military treatment facility (MTF) or the PCM’s office.
The MTF is always the primary source of care for TRICARE beneficiaries even if the assigned PCM is not an MTF PCM. As a result, the MTF has the “right of first refusal” to provide specialty care for a TRICARE beneficiary.
TRICARE Prime and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiaries must seek all primary health care from and coordinate other health care with their PCM. Exceptions include emergency care, clinical preventive services and outpatient behavioral health care visits, or when they choose to use the TRICARE point-of-service (POS) option.
Active duty service members (ADSMs), including those enrolled in TRICARE Prime Remote (TPR), require a referral for civilian provider specialty care. If care cannot be provided at an MTF, it is the PCM’s responsibility to refer the beneficiary to another provider.
Here are some tips for obtaining specialty referrals in the TRICARE South Region:
- Referrals should be made to network providers. Use "MyHMHS for Providers" for the Web referral option.
- The quickest way to make a referral is online at the secure provider portal, “MyHMHS for Providers.” To submit a referral via fax, complete the Patient Referral/Authorization Form (PRAF) and fax it to Humana Military at 1-877-548-1547.
- Some referrals are allowed “Specialty to Specialty.”
- Always include the sponsor’s Social Security number (SSN) and the patient’s name and date of birth (DOB) along with diagnosis and clinical data explaining the reason for the referral.
- For truly urgent referrals, call Humana Military’s Integrated Voice Response (IVR) line at 1-800-444-5445.
