24/7 nurse advice line helps troops avoid retroactive referrals

SHAW AIR FORCE BASE, S.C. -- Effective Feb. 1, the 20th Medical Group will comply with the TRICARE Management Activity guidelines and no longer create retroactive referrals for patients who do not have prior authorization for care.

By definition, a retroactive referral is a referral requested by a beneficiary after care (i.e. urgent care) has been received, that was not previously approved by their primary care manager or through the Nurse Advice Line. If the beneficiary seeks medical care without the approval of the PCM or the Nurse Advice Line, it could result in out-of-pocket expenses for the beneficiary.

What does that mean for you and your family?

For example: say it is the weekend, and one of your kids gets a really bad rash. The rash is painful, itchy and needs to be taken care of, but it is not a threat to life, limb or eyesight. Call the Nurse Advice Line and they will guide you through what to do for that situation. If needed, they will create a referral so you can take your dependent in for medical treatment and get that rash taken care of.

However, if the situation involves a threat to life, limb or eyesight, call 911 or seek immediate medical attention at the nearest emergency room.

Any regular medical needs must be addressed with your PCM, who can provide referrals for you to receive specialty care with one of TRICARE’s network providers. It is your responsibility to accurately track the number of visits used, the expiration date of that referral, and to contact your PCM to obtain additional visits if needed.

Typically, you will be notified of your authorized referral within 10 business days via mail or you can view your authorization in three days by logging onto www.humana-military.com or by calling 1-800-444-5445.

Specialty care referrals do not transfer from base to base or specialist to specialist. It is imperative that you contact your PCM prior to any specialty care and after any emergency or urgent care you receive.

If a beneficiary wishes to appeal a benefit-related decision made by Humana Military or file a claim, they must utilize the TRICARE claims/appeals process.

For TRICARE claims, beneficiaries have one year from the date of service to file a claim.

If the claim is filed after one year, the beneficiary must contact the regional contractor for TRICARE South (Humana) directly at 1-800-444-5445. Humana is the final review/approval authority and their decision cannot be appealed at the medical treatment facility level.

Beneficiaries who wish to appeal a decision denying payment for services/supplies must notify Humana in writing within 90 days of the date on the Explanation of Benefits or other decision letter.

Humana will review the case and issue a decision. If a beneficiary disagrees with the reconsideration, they may appeal to the TRICARE Quality Monitoring Contractor.

If the amount disputed is less than $300, the TQMC decision is final. If it is more than $300, you may appeal to the next level, the Defense Health Agency, and schedule a hearing.

Remember, it is easy to avoid a potential claim or appeal process by simply getting prior authorization for treatments from your PCM or by calling the Nurse Advice Line at 1-800-874-2273, option 1.

Health care is rarely one size fits all.

TRICARE is designed to ensure that all covered care is safe, effective and appropriate for the patient. If you have any questions, comments or concerns, please contact your TRICARE Regional Contractor, Humana, at 1-800-444-5445; visit www.TRICARE.mil or contact your MTF Health Benefits Advisor at 803-895-6230.