Humana Military Provider

Referrals and authorizations

If a necessary service is not available from the military hospitals and clinics or the patient’s Primary Care Manager (PCM), the PCM must request a referral from Humana Military. As the primary source of specialty care for TRICARE Prime beneficiaries, the military hospital or clinic has the Right of First Refusal (ROFR) to provide care for a TRICARE beneficiary.

In addition, some procedures and services, including hospitalization, require prior authorization from Humana Military. The quickest, easiest way to request a referral or authorization is via the secure self-service for providers page.

Alert to providers on new referral requirements

PRIME referral required messaging in the online “code look up” feature will be updated on April 18th to reflect the PRIME referral requirements or the codes listed below. Physician orders for the services detailed below for dates of service on or after April 18, 2016 must have a valid referral.

Code number

Service

78320

Bone imaging (3D)

78451

Ht muscle image spect sing

78452

Ht muscle image spect mult

78453

Ht muscle image planar sing

78454

Ht musc image planar mult

78469

Heart infarct image (3D)

78494

Heart image spect

78607

Brain imaging (3D)

78803

Tumor imaging (3D)

80299

Quantitation drug not elsewhere specified

87299

Antibody detection nos if

87899

Agent nos assay w/optic

88240

Cell cryopreserve/storage

88241

Frozen cell preparation

89398

Unlisted reprod med lab proc

96152

Intervene hlth/behave indiv

96153

Intervene hlth/behave group

99082

Unusual physician travel

99406

Behav chng smoking 3-10 min

99407

Behav chng smoking > 10 min

These codes are current as of 2016

  
Point of Service (POS)

When POS applies

The POS option is applied when:

  • A TRICARE Prime beneficiary receives care from a network or non-network TRICARE-authorized provider without a referral from his or her PCM.
  • A TRICARE Prime beneficiary self-refers to a civilian specialty care provider after a referral has been authorized to a military treatment facility (MTF) specialty care provider.
  • A TRICARE Prime beneficiary self-refers to a non-network specialty care provider after a referral has been authorized to a network specialty care provider. 

POS will apply to all services within the beneficiary’s episode of care such as professional provider, ancillary, anesthesia, operating room, and other inpatient or outpatient facility services-whenever there is no approved referral/authorization.

When POS doesn't apply

The POS option does not apply for services that do not require a referral such as:

  • Emergency services
  • Two Urgent Care visits per fiscal year
  • Preventive care services from a network provider
  • The initial eight outpatient behavioral health therapy visits to a network provider
  • Beneficiaries whose other health insurance is primary
  • Newborn or adoptee care (a newborn or adoptee is covered as a TRICARE Prime/TPRADFM beneficiary for the first 60 days after birth or adoption, as long as one additional family member is enrolled in TRICARE Prime/TPRADFM or the sponsor is active duty.)
  • Active duty service member care (Active duty service members who do not coordinate care through their PCM may be responsible for the entire cost of care.)
  • Ancillary services (for example, diagnostic radiology and ultrasound services, diagnostic nuclear medicine services, pathology and laboratory services, and cardiovascular studies) unless part of an episode of care that meets the POS requirements as listed above.

Using the POS option results in greater out-of-pocket expenses for beneficiaries:

Annual deductible
(applies to outpatient services only)

$300/individual

$600/family

Outpatient cost-share

50% cost-share of the TRICARE allowable amount after the annual deductible is met.Additionally, you may be responsible for up to 15% above the TRICARE allowed amount for a non-network provider.


Inpatient cost-share

50% cost-share of the TRICARE allowable amount. Additionally, you may be responsible for up to 15% above the TRICARE allowed amount for a non-network provider.

  

Peer Review Organization (PRO) agreement

To participate in the care of TRICARE beneficiaries, facilities must establish a Peer Review Organization (PRO) agreement with Humana Military in accordance with 32 CFR 199.15(g).

  • The PRO agreement is separate from a network contract and network and non-network facilities are required to sign one.
  • The agreement is a signed acknowledgement that Humana Military is the PRO for the TRICARE South Region.
  • If a corporation has multiple facilities, one signed agreement may cover all the facilities.
  • The PRO agreement confirms that the facility will cooperate with Humana Military and its subcontractors.

For more information, refer to the TRICARE Operations Manual, Chapter 7, Section 1 2008, at manuals.TRICARE.osd.mil