A quick look at the referral process: What you need to know

(U.S. Air Force photo graphic/Staff Sgt. Alexx Pons)

(U.S. Air Force photo graphic/Staff Sgt. Alexx Pons)

CANNON AIR FORCE BASE, N.M. -- You just got a referral from your Primary Care Manager and you are wondering what you should do next.
This scenario is very common for active duty service members, dependents and retirees due to the limited specialty care available at the 27th Special Operations Medical Group, but there are resources and people who can help you get the care that you need.

“You get your referral from your Primary Care Manager, and then he or she will tell you to go to the Referral Management Center,” said Gwendolyn Rundell-Williams, Director of the Referral Management Center. “The RMC will go in the system and look at the referral your provider just input, and then they will have you fill out a form to update your personal information and ask if you have had any prior studies done to forward to the specialty provider you are going to see.”

Beneficiaries will have to wait for an approval e-mail from United Healthcare Military & Veterans, which should become available within three to five business days. This e-mail will have a link to the UHC M&V website allowing the beneficiary to their view approval information. It will also have the name and contact information for the authorized specialty provider.

If a referral authorization letter is received from UHC M&V, either by mail or online, and it states that the referral is APPROVED for a “Point of Service”, stop by the RMC located in the Tricare Operations Patient Administration Office at the 27th SOMDG to ensure the referral gets processed correctly. This will prevent the patient from receiving a bill for their care. Another option is to call the RMC at 575-784-2778; select option 4, then option 1.

Beneficiaries are encouraged to register on the www.uhcmilitarywest.com website to view important TRICARE documents online instead of waiting to receive them via mail.

“Go on the UHC M&V website to get your referral number; as of Jan. 31, your paperwork is all electronic unless you opt out of that option,” said Rundell-Williams.

Once the member has their appointment information, they should call the RMC at 575-784-2278; select option 4, then option 1 for result tracking purposes. Then the beneficiary should be all set to head out to their appointment. After the appointment, specialists have 30 days to send the results back to the beneficiary’s PCM. It is recommended that patients schedule a follow-up with their PCM to go over these results.

Active duty and their dependents should also know that they may be eligible for patient travel reimbursement and to stop by the TOPA/TRICARE office for more information. It is important to bring the authorization/referral number and proof of appointment from the specialty provider (signed Doctor’s note indicating patients name, the date and time of the appointment) to process patient travel reimbursements.

“If you are referred more than 100 miles from your PCM’s office, you are entitled to the Tricare Prime travel benefits,” said Rundell-Williams. “Active duty has the option to create orders for their dependents utilizing the Defense Travel System and will get the information to create the orders when they stop by the TOPA/TRICARE Patient Travel Reimbursement Office.”

Beneficiaries will also receive an e-mail with the explanation of benefits detailing the services provided.

“This is your guide to know what is paid for and what has not been paid,” said Rundell-Williams. “It shows what services you received from the specialist provider, and beneficiaries are able to challenge charges for services listed but not performed.”

Beneficiaries should be sure to check the “Patient Responsibility” line on the explanation of benefits because this will show the outstanding balance that you as the patient are financially responsible for.

For more information, you can refer to any of the follow:
UHC M&V website to view authorizations/referrals
UHC M&V phone number to obtain authorization/referral number: 1-877-988-9378
Referral Management Center phone number: 575-784-2278; select option 4, then option 1
TOPA/TRICARE Patient Travel Reimbursement office: 575-784-6975