Referral Management

The Right of First Refusal (ROFR) process gives the military hospital or clinic the right to provide specialty care to a Prime beneficiary when available.

Things to know about ROFR:

• ROFR is a requirement under the Prime plan
• Only applies to Prime beneficiaries living within a 60 minute drive of a military hospital or clinic or who have waived their access to care standards to remain enrolled in Prime
• During Open Season, Prime beneficiaries can change to the Select plan where ROFR is not a requirement
• When care is received at a military hospital or clinic, there is no copay
• If a referral is accepted by the military hospital or clinic under ROFR, Humana Military cannot change the referral, only the military hospital or clinic can approve it to be changed to a civilian provider
• ROFR can only be reversed and care released to a civilian provider for continuity of care or for special circumstances that prevent the beneficiary from being able to utilize a military hospital or clinic

After it is determined a beneficiary needs to be referred for specialty care, the requesting provider will submit a referral/authorization request via web or fax to Humana Military for approval and ROFR processing.

Many times the military hospital or clinic will have the specialized services available. In this scenario, the military hospital or clinic will notify us, usually within one business day and the beneficiary will be referred to that facility.

The facility may contact the beneficiary to schedule an appointment and Humana Military will provide the beneficiary with the information for that health facility. If the facility cannot provide the services or care requested, the patient will be referred to a civilian network provider. However, it is important to understand if a provider is selected prior to the ROFR determination and the military hospital or clinic can provide the services and accepts the care, this overrides any prior provider selection, requiring the beneficiary to be seen at the military facility.