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NEWS | March 24, 2022

How referrals work with your TRICARE Prime Plan

By TRICARE Communications

Are you enrolled in a TRICARE Prime plan? Then you have a primary care manager, or PCM, to handle your basic primary health care services. But what if you need specialty treatment, like from a cardiologist to evaluate a possible heart problem or a dermatologist to check a mole that’s changed? In that case, your PCM needs to submit a referral for you to see a specialist.
Some TRICARE plans, including TRICARE Select, don’t require referrals for most health care services. However, if you’re enrolled in one of the following plans, you need a referral before you visit a specialist:
“If you’re an active duty service member or active duty family member enrolled in a TRICARE Prime plan, you need a referral from your PCM to seek most specialty care,” said Tonya Utterback, referral and authorization expert with the TRICARE Health Plan at the Defense Health Agency. “Without a referral, you may not be able to make an appointment with a specialist, or TRICARE may not be able to pay for it.”
What else do you need to know about referrals? Here are a few helpful facts about the referrals to get you started.
  •  How long is the referral process? Your PCM will send a referral request to your regional contractor, who’ll process the referral. It can take approximately three business days for your regional contractor to process your referral. It may take less time if your PCM determines your referral to be “clinically urgent” and marks it as such.
  • How can you track your referral? You can view or check the status of your referral by logging into your account on your regional contractor’s website. If you aren’t already registered for secure services, you’ll need to register first, then sign in. You can also call your regional contractor’s automated phone service. If overseas, call your TRICARE Overseas Program Regional Call Center, or check the MyCare Overseas app.
  • Where can you receive care? Your regional contractor may refer you to a military hospital or clinic or a TRICARE network provider. If a network provider isn’t available in your area, you may receive approval to see a non-network provider.
  • Can you visit a specialist without a referral? With the point-of-service option, yes. The point-of-service option allows those enrolled in a TRICARE Prime plan to visit a specialist without an approved referral from their PCM. But you’ll be subject to point-of-service charges. As outlined in the TRICARE Costs and Fees 2022 Fact Sheet, a yearly deductible before cost-sharing ($300 for individual/$600 for family) will kick in under the point-of-service option. The point-of-service option isn’t available for active duty service members (ADSMs). ADSM civilian care must be via a PCM referral with the exception of emergency care.
  • Is a pre-authorization the same as a referral? This is a little different than a referral, but still involves getting approval by your regional contractor. Sometimes, your TRICARE contractor must review a requested health care service or prescription drug to see if it’s medically necessary and a TRICARE covered benefit. This is called a pre-authorization. Some health care services require pre-authorization before you receive them, regardless of your TRICARE plan. These include adjunctive dental servicesApplied Behavior Analysishome health carehospice care, and more. Without this approval, you could be responsible for the full cost. ADSMs need pre-authorizations for all inpatient and outpatient specialty services.
Once the referral process is complete, you’ll receive an electronic authorization letter. Schedule your appointment with the health care provider listed on that letter. The authorization has an expiration date, so don’t wait too long. Want to use another provider? Then contact your regional contractor: If you’re still unsure if you need a referral or pre-authorization, you can go to the Referrals and Pre-authorizations page. If you’re seeking mental health care, check out the rules on the Getting Mental Health Care page.
Before you seek care from a specialist — or anyone other than your PCM — make sure you’re familiar with the rules of your health plan. Reach out to your TRICARE contractor if you have questions.