TRICARE provider

Referrals & authorizations

If a necessary service is not available from the military hospitals and clinics or the beneficiary's PCM, a referral will be required. Some procedures and services, including hospitalization, require prior authorization from Humana Military. The quickest, easiest way to request a referral or authorization is through provider self-service.

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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 Primary Care Manager (PCM).
  • Self-refers to a civilian specialty care provider after a referral has been authorized to a Military Treatment Facility (MTF) specialty care provider.
  • 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
  • Preventive care services from a network provider
  • Beneficiaries whose OHI 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 East 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 2015 Edition

 

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