-Q: “What is the difference between a referral and an authorization?”
A: A referral is a request placed by your PCM for consultation from a specialist or for a service not available at BHC Kingsville for a specific diagnosis. Once this request is placed, it is reviewed by clinical staff for appropriateness and if it is approved, an authorization is issued for a specific number of visits or services for a specific diagnosis. This authorization allows the civilian provider to provide a covered benefit to you as the patient. You must wait until you have an authorization to schedule an appointment with the specialist or facility you have been referred to.
-“Q: I am seeing a specialist for a specific diagnosis but I would like that specialist to look at another problem I have.”
A: Once you have an authorization for a specific diagnosis, your care from a specialist should only be for the diagnosis you originally had. If you have concerns about another problem, please see you PCM to discuss your concerns and if a specialist referral is appropriate, your PCM can place an additional referral for your concerns.
-Q: “How long does it take for my referral to be processed and for the authorization to show up on the Humana website?”
A: On average, please allow 7-10 business days for the authorization to be issued for routine consults. In some cases where a specialist or service is needed sooner, an expedited referral can be placed for emergent or urgent care.
- Q:"I want to see a different provider than the one listed on my authorization and I have never seen the provider listed on the authorization yet.”
A: Check the list of in-network providers and pick one you would prefer then call Humana to have the referral changed.
-Q: "How do I know if I have any visits left on my authorization?"
A: You are responsible for tracking the number of visits available on your authorization. You can do this several ways. You may call the civilian provider and ask how many appointments you have used and how many are remaining. You can also keep track of how many total visits have been authorized by calling Humana or by visiting the Humana website.
-Q: "How do I get more visits added to my authorization?"
A: You should be updating your PCM regularly about your progress with the specialist you are seeing. If you have not visited your PCM since your initial referral and would like more visits added, please schedule an appointment with your PCM to discuss your concerns.
-Q: "I didn't establish a therapeutic relationship with the specialist I was referred to and I do not want to go back and see him/her."
A: Please schedule an appointment with your PCM to discuss your concerns."
-Q: "My civilian specialist placed referrals through Tricare for another specialist, procedure, or service and I haven't received an authorization within the 7-10 business day window."
A: When a civilian specialist advises you that a referral will be placed for a different specialist, procedure, or service, please make an appointment or contact your PCM via secure messaging to inform us of the pending referrals. We can help ensure that these referrals are placed correctly and that you receive the care that you need.
-Q: "I am on Tricare prime remote and I have a civilian PCM but I'd like specialist referrals."
A: Your civilian PCM will need to place the appropriate referrals for you. If you are not enrolled to BHC Kingsville we cannot place referrals for you.
-Q: "I was seen in the emergency room/urgent care during clinic business hours and now I have received a bill."
A: During regular business hours, patients should be seen in the clinic for non-life threatening concerns. Should you go to an emergency room or urgent care when the clinic is open without notifying the clinic by calling the clinic (361-516-6313) you may be responsible for your medical bills. You should follow up in the clinic within one business day after visiting the emergency room or urgent care to update your PCM on your care.
-Q: “I was seen in the emergency room/urgent care and the doctor there referred me to a specialist. How do I get an authorization to see that specialist?”
-A: You should follow up with your PCM within one business day of an emergency room visit to discuss your care. Your PCM knows you and knows your health concerns better than anyone and can help determine if specialist referrals are appropriate. In addition, your PCM can place referrals for specialist care.
-Q: "I was seen in the emergency room/urgent care after-hours and now I have received a bill."
A: After hours, please call the Chief of the Day phone (361-533-7358) for authorization to go to the emergency room for any non life, limb, or eyesight threatening condition. If you do not receive permission from the after-hours on call physician to go to the emergency room or urgent care facility, you may be responsible for your medical bills.
-Q: "I went to see a specialist without an authorization and now I have received a bill."
A: You must have an authorization (not just a pending referral) prior to any visit with a specialist. If you visit a specialist without an authorization you may be responsible for paying your medical bills.
-Q: "How do I find out where I was seen for specialist care to obtain the records for my personal health record?"
A: You can call Tricare or visit the Humana military website to find the providers you have been referred to for care. To obtain records, you may request them directly from that office or you may fill out a release of information form and provide that office with the clinic fax number (361-516-6303) to have your records faxed to your PCM.