Provider Responsibilities
Network providers agree to comply with all TRICARE Prime contract requirements applicable to TRICARE network providers. Network providers (both professional and institutional) must maintain medical malpractice insurance coverage as required in the state in which services are provided. In the absence of state law requirements for medical malpractice insurance coverage, Humana Military will determine the local community standard for medical malpractice coverage for network providers. Each network provider must maintain the required medical malpractice coverage.
Consult Reports
Consult reports are required to be returned to the primary care manager (PCM) or initiating provider within 10 working days of the patient encounter. Routine specialty referrals for initial office visits, all outpatient services, and inpatient services must provide complete and legible documentation for these reports to be accurate and useful. Consult reports, operative reports, and discharge summaries returned to the initiating provider are important for timely follow up and continuity of care. Please be responsive to the request when asked to return a consult report for TRICARE beneficiaries.
Providers who treat TRICARE beneficiaries coming from the local military treatment facility (MTF) may receive a fax reminder to return a consult report for a recent visit or service. Your office should return the consult report, operative report, or discharge summary requested and use the designated fax reminder as the cover sheet. Please use the fax number shown in the center of the reminder page. This fax number is shown only on the fax reminder sent to providers for each beneficiary consult return request. This is to avoid having providers send documentation on all other TRICARE beneficiaries.
Office and Appointment Access Standards
One of the contract requirements for all network and MTF providers is to meet all office and appointment access standards. Those standards are as follows:
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Emergency services must be available 24 hours a day, seven days a week.
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Maximum wait times for appointments are:
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One day for acute illness
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One day for the initial urgent behavioral health care appointment with a behavioral health care provider
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One week for routine visits (health problems that are non-urgent)
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One week for the initial routine behavioral health care appointment with a behavioral health care provider
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Four weeks for wellness (preventive health) visits
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Wait time for specialty care appointments will be based on the nature of the care required, but will not exceed four weeks (28 days). The PCM determines the level of urgency.
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Office waiting times for nonemergency situations will not exceed 30 minutes. Providers who are not able to adhere should notify the patient and offer to reschedule.
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Patients calling after hours who are not suffering from conditions requiring emergency care should be offered the following guidance:
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Put in contact with an “On Call” network physician covering for you or your practice
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Offered self-care advice
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Offered a next-day appointment when appropriate
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Directed to an urgent care center that participates in the TRICARE program
Missed Appointments
TRICARE regulations do not prohibit providers from establishing practice policies regarding no-show fees. Providers who, as part of their practice standards, require beneficiaries to sign an agreement taking financial responsibility for missed appointments are within their rights to charge beneficiaries for missing an appointment. However, if no formal agreement is in place, the provider may not bill the beneficiary for the missed appointment.
TRICARE does not reimburse charges formissed appointments.
Urgent and Emergency Care
In urgent and emergency situations, a preliminary report of a specialty consultation should be submitted by the network provider to Humana Military within 24 hours. Telephone reports to the MTF can be coordinated based upon the urgency of the condition. Please be sure to fax the report to Humana Military, as well, for completion of electronic records. Refer to the Medical Coverage section of this handbook for more information on emergency and urgent care services.
"An Important Message from TRICARE"
Inpatient facilities are required to provide each TRICARE beneficiary with a copy of the document “An Important Message from TRICARE.” This document details the beneficiary’s rights and obligations upon admission to the hospital. The signed document must be kept in the beneficiary’s file. A new document is needed for each admission.
Hold Harmless Policy
A provider may not require payment from a TRICARE beneficiary for any excluded or excludable services the beneficiary received from the network provider (i.e., the beneficiary will be held harmless) except as follows:
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If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided.
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If the beneficiary was informed that the services were excluded or excludable and he or she agreed in advance to pay for the services, the provider may bill the beneficiary.
Updating Provider Information
It is important for Humana Military to have the most current and accurate data concerning your practice to facilitate timely claims payment and correspondence. Notify Humana Military of any changes in your status, address, phone, or fax numbers by calling 1-800-444-5445.
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