Referrals and Pre-authorizations

Know when you need a referral or pre-authorization before you see a provider. This can help you get the care you need without delays or surprise bills.

What’s the Difference Between a Referral and a Pre-authorization?

A referral is when your PCM sends you to another provider, often a specialist, for specialized care.

A pre-authorization is when Humana Military ensures planned services or procedures are covered by TRICARE before it is provided.

See Referral and Authorization FAQs

Whether you need a referral depends on your TRICARE plan and your status.

Active Duty Service Members

When Do I Need a Referral?

If your PCM at a military hospital or clinic can’t provide the services you need, they’ll work with TRICARE East to get a referral or authorization for a civilian provider.

When Don’t I Need a Referral?

• For urgent care at the military hospital.
• For emergency care at an emergency roomThe hospital department that provides emergency services to patients who need immediate medical attention..

Note: If you get care that requires a referral without getting one beforehand, you may have to pay all or part of the bill.

TRICARE Prime

When Do I Need a Referral?

• For clinical preventive services when visiting a non-network provider.
• For specialist visits and some diagnostic services. Your PCM will handle the referral process with TRICARE East.
• Certain services require pre-authorization, or approval, for TRICARE East for your care, like inpatient admissions and some mental health services.

Note: If you go to a specialist without a referral, you’ll use your point-of-service option.

When Don’t I Need a Referral?

• To get clinical preventive services from any network provider without a referral.
• For any urgent care services.

TPR

When Do I Need a Referral?

• If your PCM at a military hospital or clinic can’t provide the services you need, they’ll work with TRICARE East to get a referral or pre-authorization for a civilian provider.

When Don’t I Need a Referral?

For urgent care if you see a TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS.

• There are two types of TRICARE-authorized providers: network and non-network.

For care at an emergency room for a true emergency. Note: If you receive care that requires a referral without getting one, you may be responsible for all or part of the bill.

TRICARE Select and Other Beneficiaries

When Do I Need a Referral?

• You don’t need a referral for services.

When Do I Need Pre-Authorization?

• Some services, like ABA and inpatient admissions, require pre-authorization. • You can see any TRICARE-authorized provider, whether network or non-network.

USFHP

• If you have the USFHP, please call 800-74-USFHP or 800-748-7347 for information about your plan.

How Can I Check My Referral Status?

To check the status of a referral, log in to your self-service account. After a provider submits a referral, it could take 1-2 business days for it to show up.

What Else Do I Need to Know?

• If a provider isn’t TRICARE-authorized on the date of service, the claim will be denied.
• If the provider doesn’t submit certification paperwork, you must pay all charges.