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When a TRICARE Prime beneficiary’s primary care manager (PCM) is unable to provide a specialized medical service, the PCM must contact Humana Military Healthcare Services, Inc. (Humana Military) to request a referral. Humana Military issues a referral when a TRICARE Prime beneficiary needs specialized medical services from a civilian professional or ancillary provider only if services are not available at the military treatment facility (MTF) or at the PCM’s office. The MTF is always the primary source of care for TRICARE beneficiaries. The MTF has the “right of first refusal” to provide care for a TRICARE beneficiary.
Referral requests may be submitted online via the “ MyHMHS for Providers”. See “ Provider Resources” in the Welcome to TRICARE and the South Region section for more information about online referral requests.
Note: Active duty family members (ADFMs) enrolled in an overseas TRICARE Prime options, including TRICARE Global Remote Overseas (TGRO), do not require a referral and authorization for care when traveling in the United States, and point of service (POS) fees do not apply to them.
Tips for Making Referrals
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All referrals must be made to network providers. Network providers are listed in the “ Find a Provider” feature.
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Submit a referral on the Web site, via fax, or by phone.
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The quickest way to submit referral information is online via the “ MyHMHS for Providers” portal. Web site referral services are automated and, in many cases, provide immediate response and confirmation.
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For behavioral health referrals, contact ValueOptions, Inc. (ValueOptions) at 1-800-700-8646.
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When completing the referral, always include the sponsor’s Social Security number (SSN), diagnosis, and clinical data explaining the reason for the referral.
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Check referrals via MyHMHS for Providers. To check the referral status by phone, call Humana Military’s Interactive Voice Response (IVR) line at 1-800-444-5445 and select the option, “To check the status of an authorization or previously requested service.”
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The PCM and the referred provider will receive an auto fax when the care is authorized. Authorization is based on whether or not the referral is for a covered service.
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The auto fax will specify the services authorized, the number of visits, and the time frame in which the visits must be completed.
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If services are needed beyond the scope of the referral, additional services must be approved through the PCM.
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Humana Military will notify beneficiaries of an approved referral.
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For urgent referrals, call 1-800-444-5445.
Specialist-to-Specialist Referrals for the Same Episode of Care
Some referrals may be authorized from one specialty care provider to another, bypassing the need to get another PCM referral.
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It will apply only when a valid “Evaluate and Treat” referral from the PCM has previously been authorized for the same episode of care.
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It will not apply to active duty service members (ADSMs).
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The MTF “Right of First Refusal” (ROFR) policy will remain in effect.
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The referring specialist, the receiving specialist, and the PCM will be notified of all such referrals by autofax, keeping the entire care team aware of these clinical contacts.
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Not all specialist-to-specialist referrals will be authorized.
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If a pediatric patient age 5 or younger or a patient with a developmental mental or physical disability requires dental procedures under general anesthesia, the request for prior authorization may be submitted by the dentist.
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