Getting Referrals When You Need Non-PCM Care (East Region)

This article contains information specific to beneficiaries living in the East RegionAlabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa (Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St. Louis area), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (excluding El Paso area), Vermont, Virginia, West Virginia, and Wisconsin.. Check the map to find your region.

If you’re enrolled in TRICARE Prime, sometimes you may need care your primary care manager (PCM) or military hospital or clinic can’t provide. In this case, your PCM may refer you to the private sector for care.

A referral is when your PCM or provider works with Humana Military to send you to another provider for care that they don’t provide. Below are some answers to common questions about referrals to help you better understand the referral process.

When do I need a referral?

Are you an active duty service member (ADSM) with a PCM at a military hospital or clinic? If so, your PCM will refer you to another military hospital or clinic provider for any care they don’t provide. If the military hospital or clinic can’t provide the services you need, they’ll work with Humana Military for a referral or pre-authorization to seek care from a civilian network provider. Exceptions include:

• Urgent care at the military hospital or clinic. This is for medical conditions that aren’t emergencies but still need professional attention within 24 hours. ADSMs need a referral for private sector urgent care if the military hospital or clinic can’t provide the services.
• Emergency care through an emergency roomThe hospital department that provides emergency services to patients who need immediate medical attention. for a true emergency. This means an illness or injury that threatens your life, limb, sight, or safety. Examples include broken bones, spinal cord injuries, severe eye injuries, severe bleeding, chest pain, and the inability to breathe.

What about TRICARE Prime enrollees who aren’t ADSMs? You may receive clinical preventive services from any network provider without a referral or pre-authorization. You’ll need a referral to see a non-network provider. Specialist office visits and some diagnostic services require a referral. Your PCM works with Humana Military for the referral and authorization. Urgent care visits don’t require a referral.

You don’t need a referral for most medical services if you’re enrolled in:

• TRICARE Select
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE For Life

Keep in mind, your child needs a referral for applied behavior analysis offered under TRICARE’s Autism Care Demonstration.

Why do I need to get a referral?

If you don’t get a required referral before receiving care, you may be responsible for point-of-service (POS) option charges. You’ll pay more for care than you would if you followed the TRICARE Prime referral rules. You may also be responsible for the entire bill if the provider you see is out of network and provides you non-covered care.

How do I get a copy of my approved referral, and what do I do with it?

Log in to the beneficiary self-service portal to view and check the status of your referral. When approved, you’ll see an electronic authorization letter. This letter includes the provider you’ll see, the number of visits you can make, and the date of expiration. Most referrals are good for 180 or 365 days. However, some referrals have different expiration dates. Be sure to check your authorization letter to confirm when your referral expires.

Once you have your referral, call the listed provider to make an appointment.

You can contact Humana Military if you have these concerns:

• Can’t get a specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide. appointment within four weeks
• Want to see a different provider
• Want to change your provider because it’s more than 60 minutes from your home.