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Referrals
      


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 the requested services are not available at the military treatment facility (MTF) or at the PCM’s office. The MTF is always the primary source of specialty care for TRICARE Prime beneficiaries, and has the “right of first refusal” to provide care for a TRICARE beneficiary.

Referral requests may be submitted online via the “MyHMHS for Providers” portal.  See “Provider Resources” in the Welcome to TRICARE and the South Region section of this handbook for more information about online referral requests.

Note: Active duty family members enrolled in TRICARE Overseas Program (TOP) Prime or TOP Prime Remote do not require referrals and authorizations for care when traveling in the United States, and point-of-service (POS) fees do not apply to them.

Figure 7.1 provides tips for making referrals.

You should also keep in mind the following information when making referrals:
  • All referrals must be made to network providers. Network providers are listed in the “Find a Provider” feature.
  • When completing the referral, always include the sponsor’s Social Security number (SSN), diagnosis, and clinical data explaining the reason for the referral.
  • The PCM and the referred provider will receive an automatic fax when care is authorized. Authorization is based on whether or not the referral is for a covered service. The automatic fax will specify the services authorized, the number of visits, and the time frame in which the visits must be completed.
  • If the patient needs services beyond the referral’s scope, the PCM must approve additional services.
  • Humana Military will notify beneficiaries of an approved referral.
  • For urgent referrals, call 1-800-444-5445.

Figure 7.1 Tips for Making Referrals

Type of Referral Submission Check Status
General
(non-behavioral health care)		 Web site: 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.

Fax: You may also fax the Patient Referral Authorization Form (PRAF). The Humana Military Healthcare Services, Inc. (Humana Military), PRAF fax number is 1-877-548-1547. 		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.
Behavioral health care Contact ValueOptions, Inc., at 1-800-700-8646 Check referrals via MyHMHS for Providers

To check the referral status by phone, call Humana Military’s IVR line at 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 for another PCM referral.

Specialist-to-specialist referrals:
  • Apply only when a valid “Evaluate and Treat” referral from the PCM was previously authorized for the same episode of care
  • Do not apply to active duty service members (ADSMs)
  • Are subject to the MTF “right of first refusal” policy
If you are a specialist referring your patient to another specialist, please keep in mind:
  • You, the receiving specialist, and the PCM will be notified of all such referrals by automatic fax, keeping the entire care team aware of these clinical contacts.
  • Not all specialist-to-specialist referrals will be authorized.
  • 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 prior authorization request may be submitted by the dentist.

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Last Update: January 15, 2011