This means that the provider ID you are signed in with is not listed anywhere on the authorization/referral (auth). If the Provider ID you are signed in with has an AFFILIATION with a Provider ID listed on the auth and you still get this message, you will need to contact your TRICARE Service Center to make sure the affiliation exists in our system.
If you requested this auth via the web site, then you were most likely signed into our system under a different provider ID when you created it. To view the auth, simply exit the Referral and Authorization system using the Exit button in the upper right corner of the screen, switch your current Provider ID to the one you created the auth with in the My Profile area on the right of the MyHMHS for Providers screen and click on the Check and existing Referral/Auth link.
Services for TRICARE Prime beneficiaries may require referrals or authorizations based on the diagnosis and procedure. Services for TRICARE Standard beneficiaries do not require referrals. However, if the beneficiary chooses to go to a network provider, they will receive a higher level of benefits, i.e. lower out of pocket costs to the beneficiary, known as "TRICARE Extra."
In general, you should reference the TRICARE Provider Handbook or for registered users of the HMHS Web site - access the "Code Inquiry" function located within the Authorizations/Referals section of this Web site. HMHS Online Provider Web-based applications require secure log-in. The South Region Prior Authorization List was updated on April 1st, 2007. Follow the link below to the new Prior Authorization List.
Using the MyHMHS for Providers Referrals/Auths Code Inquiry feature gives you the most up to date information for each CPT code. Enter the code to find out if it's a non-covered benefit, Prime Referral Required, Prior Auth Required or Exempt. Follow the link below to the home page for MyHMHS for Providers.
For Prime beneficiaries, maternity authorization requires:
1. An initial referral to the OB specialist to confirm the pregnancy and cover pre- and post-natal office visits
2. An inpatient authorization for the delivery, which will cover the facility charge and all professional charges associated with the delivery.
The referral is for an initial visit and all subsequent routine maternity care visits as long as the date of service is prior to the referral's expiration date. Non-maternity related care within the OB provider's office during pregnancy is allowed without a referral from the PCM. The inpatient authorization covers the hospital and professional claims for the delivery. For any other pregnancy related inpatient admission or services other than delivery, a separate referral or admission authorization is required. Although it is not required, if Humana Military is notified of an observation stay, the referral will be entered.
Maternity related ultrasound is limited to the diagnosis and management of conditions that constitute a high-risk pregnancy (as defined in 32 CFR 199.2) or which present a reasonable probability of neonatal complications. The claim is reviewed for a high risk pregnancy diagnosis.
For Standard beneficiaries, an inpatient authorization is required for the delivery.
Humana Military conducts medical necessity reviews by using InterQual criteria as published by McKesson of Marlborough, Massachusetts. InterQual criteria are certified by URAC. InterQual clinical decision support content is based on well-researched medical evidence that is reviewed and updated annually.
To improve coordination of care, TRICARE requires a consult report on a referral be provided to the initiating physician within 10 working days of the visit. Please fax your report to Humana Military within eight working days of the visit and Humana Military will forward the report electronically to the PCM.
When a referral or authorization is denied, an initial determination letter is sent to the beneficiary and the provider explaining the decision. Appeal rights are outlined in the letter with instructions on how, when and where to file a request for reconsideration of the denial.
Persons or providers who may appeal are limited to:
The TRICARE beneficiary (including minors)
The participating provider of services (except network providers whose recourse is through the contractual provision for appeal or the state court system), or
A non-network provider appealing a preadmission/preprocedure denial (when services have not been rendered) or
A provider that has been denied approval as an authorized TRICARE provider or who has been terminated, excluded, suspended, or otherwise sanctioned.
If the proper appealing party cannot or does not wish to pursue the appeal personally, or wishes to have another person directly assist in pursuing an appeal, the appealing party may appoint a representative to act on his or her behalf at any level of the appeal process. The appointment of a representative must be in writing and must be signed by the proper appealing party. An individual may also be appointed to act as a representative for the appealing party by a court of competent jurisdiction.
Within Prime service areas, the Military Treatment Facilities (MTFs) have the right of first refusal for all referrals. Each MTF determines which referral requests they want ot receive based upon specialty, selective diagnosis code, procedure codes and/or enrollment category. These referral requests are provided to the MTF prior to medical necessity and covered benefit review to provide the MTF the opportunity to see the patient prior to any decision.
You can update the actual service date on the referral or authorization by accessing it through the MyHMHS for Providers referral and authorization function on the Humana Military website at www.humana-military.com.
The TRICARE Reimbursement manual Chapter 1, Section 16, III, H states that a second and/or third opinion can be "patient initiated": therefore, a PCM referral is not required.
