Specialty care responsibilities

Specialty care may require prior authorization from Humana Military as well as referrals from Primary Care Managers (PCM) (for TRICARE Prime enrollees).

TRICARE Prime beneficiaries who live within a 60-minute drive time of a military hospital or clinic may be required to first seek specialty care, ancillary services and physical therapy at the military facility based on its Right Of First Refusal (ROFR).

PCMs and/or specialty care providers must coordinate with Humana Military to obtain referrals and prior authorizations. A network provider who submits a claim for an unauthorized service is subject to a penalty of up to 50 percent of the TRICARE allowable charge and the beneficiary may be held harmless.

Network behavioral healthcare providers have agreements to follow rules and procedures regarding behavioral health. Although a PCM referral is not required for these services (except for Active Duty Service Members (ADSM), prior authorization may be required.

Care rendered without prior authorization will be reviewed retrospectively and may result in a penalty of up to 50 percent. The cost of this penalty will be borne by the provider, and the beneficiary is held-harmless.

Specialty referral requirements vary by TRICARE beneficiary type and program option:

  • TRICARE Prime: ADSMs: PCM and/or Humana Military referrals are required for all civilian specialty care. In addition, prior authorization from Humana Military is required for certain services.
  • Active Duty Family Members (ADFM): PCMs should refer patients to military hospitals and clinics or network providers whenever possible. ADFMs must obtain PCM and/or Humana Military referrals for any care they receive from providers other than their PCMs, except for preventive care services from network providers, behavioral healthcare visits for medically necessary treatment for covered conditions by network providers who are authorized under TRICARE regulations to see patients independently or when using the Point-Of-Service (POS) option. In addition, prior authorization from Humana Military is required for certain services.
  • TRICARE Select: Beneficiaries may self-refer to TRICARE-authorized specialty care providers. However, prior authorization from Humana Military is required for certain services.
  • TRICARE For Life: Beneficiaries may self-refer to Medicare-certified providers. However, prior authorization from Humana Military is required for certain services.

Providers should request referrals and prior authorizations via provider self-service. Humana Military only accepts requests via fax if the provider is not able to submit electronically.

If a civilian specialty provider refers a TRICARE patient to a subspecialist, the specialty provider must contact the patient’s PCM when subspecialty care is outside of the scope of the initial referral and/or prior authorization. If required, the PCM must request a new referral and/or authorization from Humana Military.

If active (i.e., already approved) referrals and/or prior authorizations are in place, specialists can request additional visits or services directly from Humana Military. View referral and prior authorization requirements

Note: If the PCM refers a patient for a consultation only, Humana Military issues a referral for an initial consultation and one follow-up visit. Specialists cannot request additional visits or services for consult-only authorizations. The beneficiary must coordinate further care with his or her PCM. If additional services beyond the scope of the initial referral are required, the specialist must send another request to Humana Military to ensure continuity of care.