Information about TriCare Prime referrals

  • Published
  • By Stephanie Bemrose
  • The Bombardier
BARKSDALE AIR FORCE BASE, La. --  Barksdale TRICARE Prime beneficiaries assigned to 2d Medical Group are reminded to know the procedure for referrals.

TRICARE Prime members must have a referral prior to going to an off-base provider, emphasized 1st Lt. Steve Martin, TRICARE Operations and Patient Administration Flight commander.

The process to get a referral begins with a patient's Primary Care Manager, who determines if a referral is needed, explained Patricia Oakes, chief of the Referral Management Center.

The RMC receives and reviews each referral to determine if the service requested can be offered in the military treatment facility. If it is not available, the referral is deferred to Humana Military Healthcare Services, and a network provider is selected. The patient can select a network provider if they stop by the RMC after the PCM enters the referral. Then the authorization letter will arrive by mail.

"The authorization letter will specify who the appointment is with, how many visits you are authorized and when the referral expires," Lieutenant Martin said. "People need to understand that they need a referral for all non-emergent health care."

It usually takes 7-10 business days for the letter to arrive, Ms. Oakes added, but the same information is usually posted on their website in three to five days at www.humana-military.com.

"The RMC schedules all STAT, ASAP, PRP patients, Flying Status patients and all specialty clinic appointments within the medical group while the patients are at the RMC," she added. "Therefore, it is important they stop by the RMC after each referral."
If there is threat to life, limb or sight, the patient should seek care from the nearest emergency room, not an urgent care center.

"The patient should notify their PCM of the ER visit as soon as possible. Claims will pay appropriately without a referral for a true emergency situation only," Ms. Oakes emphasized.

Ms. Oakes explained that when TRICARE Prime patients are out of the local area, they can only be authorized services for conditions that require urgent or emergent care.

"If it is a chronic condition or routine issue, they should not seek referral for that condition, but wait to be seen by PCM upon their return," Ms. Oakes said. "Patients should always make sure they have an ample supply of routine medications with them for this reason. If the patient is going to be out of the area for more than 30 days, they should enroll to a PCM in that local area to avoid any problems with referrals. This will allow them to seek care for any condition they may have."

The cost of health care is rising and is predicted to become 12 percent of the Air Force budget by 2015, which is in the billions of dollars, explained Lieutenant Martin.
Barksdale members may have to pay for a visit that did not have the proper pre-authorization.

Visit the 2d MDG or call the RMC at 456-6562 for more information.