Page 84 - R2P Front Desk Manual v1

Tricare Information

Basic plan information:
1. Tricare Prime: referral & auth are ALWAYS required from Primary Care Manager
(PCM).
a. Prime Active Duty Service Member / Family Member - 100% covered
b. Prime Retiree - will always have a copay
2. Tricare Select: does not require a referral.
a. Authorization may be required after the patient’s 16th visit - we have been given
conflicting information regarding this requirement, so it is best to submit a request
for authorization through the online portal just in case.
3. All plans are based on the calendar year.
4. “Catastrophic Cap” = Out of Pocket maximum

Regarding referrals:
● R2P’s Provider Information must be listed on the referral.
○ The R2P address on the referral is the only location at which the patient can be
treated. If the address is incorrect, the patient must contact Tricare/their PCM
and ask them to change to correct address and an updated referral will be faxed.
● If a patient needs more visits past the # approved on initial referral (almost always 16)
for continued treatment, the clinic can request additional authorization through the online
portal or via phone and submit/fax documents for review.
○ The request can get approved automatically and faxed within 1 hour, or it will
have to be reviewed and can take up to 3 business days to be approved.
■ Can check the status of a request via the online portal, or clinic can call
Humana to check on status at any time.
■ Most common reasons referrals don't get approved right away are
because of too many visits requested or doing something different than
was on referral; recommends requesting 16 or less visits.
● If a referral expires or the original referral is greater than 6 months old, then the patient
must obtain a new referral in order to be seen.
● If a referral says "Evaluate Only" - clinic can only look at the beneficiary & do whatever is
on referral (very rare to see this - usually says “Evaluate & Treat”).
● If the beneficiary changes their PCM during treatment, they must receive a new referral
from the new PCM.
● The clinic can call in an urgent referral to Humana rep if the beneficiary is in great pain
and their appointment is in the next 48 hours.
If a patient comes in without a referral:

Last Update: 7/11/19