Right Of First Refusal (ROFR)

Military hospitals and clinics have the Right Of First Refusal (ROFR) to provide care for a TRICARE beneficiary.

Right Of First Refusal (ROFR)

The ROFR process

In accordance with the TRICARE Operations Manual, Chapter 8, Section 5.1, “The referral request for beneficiaries residing within the PRIME Service Area shall follow the Right Of First Refusal allowing the local military hospital or clinic priority. Access standards, enrollment category, available specialty, as well as diagnosis and requested services/procedures are considered affording the military hospital the opportunity to see the patient….”

After it is determined a beneficiary needs to be referred for specialty care, the requesting provider will submit a referral/authorization request via web or fax to Humana Military for approval and ROFR processing.

Many times the military hospital or clinic will have the specialized services available. In this scenario, the military hospital or clinic will notify us, usually within one business day, and the beneficiary will be referred to the military hospital or clinic. The military hospital or clinic may contact the beneficiary to schedule an appointment, and Humana Military will provide the beneficiary with the information for contacting the military hospital or clinic.

If the military hospital or clinic cannot provide the services or care requested, the patient will be referred to a civilian network provider. However, it is important to understand if a provider is selected prior to the ROFR determination and the military hospital or clinic can provide the services, and accepts the care, this overrides any prior provider selection requiring the beneficiary to be seen at the military hospital or clinic.

Tips for ensuring the ROFR process is working in your office:

  • Build/request referrals using the options available to your office using provider self-service or by faxing a referral/authorization request using the Patient Referral Authorization Form (PRAF)
  • Understand that even if you select a provider to refer to, the local military hospital or clinic may review and override the referral selection, applying the ROFR
  • Ensure the beneficiary is aware the military hospital or clinic may take precedence on the referral selection

Military hospitals and clinics and ROFRs

Military hospitals and clinics are located on most military posts, bases and installations. Their primary focus is active duty readiness for military contingency operations. The military hospital or clinic is also responsible for TRICARE families and may choose to have Prime-referred services delivered within the military hospital or clinic for a number of reasons:

  • To enhance the military graduate medical education program
  • To hone the skills of military providers rotating through the military hospital or clinic nearest you
  • To ensure military hospital and clinic optimization, which helps to contain healthcare cost for TRICARE beneficiaries
  • To assist in determining prevalent military hospital and clinic specialty access and adequacy needs for a particular TRICARE population