FALLS CHURCH, Virginia –
You’ve likely heard the term “referral” in connection with health care. But what exactly is a referral — and how do you know if you need one? A referral is when your primary care manager, or PCM, or primary care provider sends you to another provider or specialist for care.
“When you receive a referral for care, your provider has determined the care will benefit your health,” said Tonya Utterback, referral and authorization expert with the TRICARE Health Plan at the Defense Health Agency. “Once your referral is approved, it’s important to use it in a timely manner. For example, if you’re referred to a cardiologist to evaluate a heart problem, diagnosing and treating the problem as soon as possible may result in a better health outcome.”
Read on to learn when you need a referral and helpful tips for using them.
Q: Do I need a referral?
A: It depends on your beneficiary category, which TRICARE plan you use, and the type of care you need.
If you’re an active duty service member, or ADSM:
- You need a referral for any medical care your PCM doesn’t provide. This includes urgent, routine, preventive, and specialty care.
- If you get care without a referral, you may have to pay out of pocket.
If you use a TRICARE Prime plan (including TRICARE Prime Overseas) and you aren’t an ADSM:
If you use a TRICARE Select plan or TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE For Life, you don’t need a referral for most medical services. However, your child needs a referral for applied behavior analysis.
Q: How long does it take to get a referral?
A: Your provider will send a referral request to your regional contractor. It can take approximately three business days to process your referral.
Q: Where do I find my referral?
A: Log in to your beneficiary self-service portal on your regional contractor’s website to view or check the status of your referral. (You’ll need to create an account if you don’t have one.) You can also call your regional contractor’s automated phone service.
If overseas, you can check your MyCare Overseas mobile app or web-based portal. You can also call your TRICARE Overseas Program Regional Call Center.
Q: What should I do when my referral is approved?
A: When your referral is approved, you’ll receive an electronic authorization letter. This letter will be in your beneficiary portal. The letter will outline:
- The reason for the referral
- The provider you’ve been referred to
- The care and number of visits you’re approved to receive
- The date the referral expires
To make your first appointment, contact the provider named in the letter.
Contact your regional contractor if any of the following apply to you:
- You can’t get an appointment within four weeks
- You want to see a different provider
- The provider you’re referred to is more than 60 minutes from your home and you want to change your provider
- Overseas, if you encounter a language barrier when booking an appointment
Q: How long does my referral last?
A: Most referrals are valid for up to 180 or 365 days. However, some referrals have different expiration dates. Check your authorization letter to confirm when the referral expires.
If you have ongoing specialty care needs, you should request a new referral from your primary care provider before the referral expires. To avoid potential gaps in care, request your referral at least 30 days before your existing referral expires.
If your referral expires and you still wish to receive specialty care, you must request a new referral from your doctor.
Q: What should I bring to my first appointment with a specialist?
A: Bring your military ID and referral authorization letter to your appointment. When you schedule your appointment, ask about what other materials your specialist needs. For example, you may need to provide copies of medical records, X-rays, or lab results. The specialist may coordinate with your referring provider to get these materials. In this case, you may be asked to sign a release of information. If you need materials from a military hospital or clinic, request them several days in advance of when you’ll pick them up.
Q: Can I be reimbursed if I need to travel for specialty care?
A: The Prime Travel Benefit reimburses reasonable travel for a qualified trip by a TRICARE Prime enrollee. Visit Travel Reimbursement for Specialty Care to learn if your trip is eligible and how to use this benefit.
Q: How can I find more information?
A: Contact your TRICARE contractor if you have questions about referrals. You can also learn more on their websites:
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