CHARLESTON AIR FORCE BASE, S.C. –
As a TRICARE Prime beneficiary enrolled to the 437th Medical Group, your Primary Care Manager team includes a medical provider, nurse and technician. This team is your key to gaining the best healthcare services available as a TRICARE Prime enrollee. Your PCM team will assist you in getting the right care at the right time. The bottom line is that we want to take care of you, and when appropriate, help you take care of yourself.
The PCM teams provide primary medical care in our medical treatment facility. In the event you need to see a specialist for diagnosis or treatment, your PCM team can refer you to specialists as needed. Properly obtaining referrals before seeking care outside the MTF will decrease the risk of unexpected bills.
How do I get a referral for specialty care?
The PCM teams enter a computerized referral for you to receive evaluation and treatment from a specialist outside of the 437th Medical Group. Humana (TRICARE), based out of San Antonio, processes the referral and mails you an authorization letter for the care. A referral to a civilian office generates a bill and the authorization from Humana pays the bill.
What is an authorization for care?
An authorization is a contract for payment from Humana to the specialist your PCM team referred you. An authorization is generally to see one specialist for only six months and only three visits. If you need more time or more visits added to your authorization, call our Referral Management Center nurses at 963-6901 or 963-6994 before your authorization expires.
What if the specialist needs to do a procedure or surgery?
In many cases the specialist may recommend a diagnostic procedure or surgery. The specialist must obtain a prior authorization from Humana before you receive the treatment. As stated in the TRICARE Prime Handbook, a prior authorization is a process of reviewing medical and surgical services to ensure medical necessity and appropriateness of care prior to services being rendered. Your specialist will request authorization directly from Humana for the specific procedure or surgery. If you have a question about which specific services or procedures require prior authorization, call Humana at 1-800-444-5445.
How do I check on the status of my referral entered by my PCM Team?
After your PCM team enters a referral for you, it moves through the authorization process to Humana in San Antonio and may take up to 10 working days for final approval. Once approved, Humana will mail an authorization letter to your address in Defense Enrollment Eligibility Reporting System. If after 10 days you have not received the letter, call Humana at 1-800-444-5445 to obtain a status update.
It is our privilege to take care of your healthcare needs. Please address additional questions to the 437 MDG Referral Management Center nurses at 963-6901 or 963-6994.