Providing Care to Beneficiaries from Other Regions
Emergency Care
Under all TRICARE programs, no referrals or authorizations are required for TRICARE beneficiaries receiving emergency care inside or outside of their TRICARE regions. However, TRICARE Prime beneficiaries must contact their PCMs or regional contractors (e.g., Humana Military; Health Net Federal Services, LLC; TriWest Healthcare Alliance Corp.) within 24 hours of an inpatient admission, or the next business day, to coordinate ongoing care.
Urgent Care
TRICARE Prime beneficiaries must receive referrals from their PCMs or regional contractors for urgent care. If a TRICARE Prime beneficiary does not receive a referral, the claim will be paid under the POS option.
If you provide emergency or urgent care services to a TRICARE beneficiary from a different region, the beneficiary will be responsible for paying the applicable cost-share, and you will submit reports and claims information to the region in which the TRICARE beneficiary resides, not the region in which they received care.
Note: If the condition that prompted the emergency care is found to be routine and there is no evidence that the condition ever appeared to be anything other than routine, the care will be covered under the POS option for TRICARE Prime beneficiaries. Exceptions are made if the beneficiary was referred to the emergency department by his or her PCM or regional contractor.
If you have questions about processing claims for beneficiaries from other regions, contact Humana Military at 1-800-444-5445.
Routine Care
TRICARE beneficiaries are instructed to receive all routine care, when possible, from network providers in their designated regions. However, in some cases beneficiaries will receive routine care in another region. In such cases, the following guidelines apply:
- TRICARE Standard beneficiaries will pay applicable cost-shares, and providers will submit claims to the regions where beneficiaries reside, not the region in which they received care.
- TRICARE Prime beneficiaries will receive referrals from their PCMs or regional contractors for out-of-region care and will pay applicable cost-shares. Providers will submit claims to the region where the beneficiary resides, not the region in which he or she received care. If a TRICARE Prime beneficiary does not receive a referral for out-of-region care, claims will be paid under the POS option.
See the Claims Processing and Billing Information section of this handbook for more information. If you have questions about processing claims for beneficiaries from other regions, contact Humana Military at 1-800-444-5445. |
