Q&A: TRICARE beneficiary specialty care referrals

The referral process can be complex, but TRICARE East has systems in place to help you.

If a civilian provider determines you need specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide., they’ll submit a referral request to TRICARE East. Often, a nearby military hospital or clinic assigns a specialist from the hospital or clinic to provide you with care. After it makes the assignment, it will notify TRICARE East within three business days. Next, TRICARE East will refer you to that military hospital or clinic.

This process lets the military hospital or clinic serve as the first option to provide specialty care. If the military hospital or clinic can’t provide the services, then TRICARE East will refer the care to a civilian network provider.

1. Who does this process apply to?

If you’re a beneficiary with TRICARE Prime who lives within the 60-minute access to care standard, TRICARE East may first refer you to a military hospital or clinic. This also applies to you if you have TRICARE Prime and have waived your access to care drive-time standard.

Note: If you have TRICARE Select, you don’t have to get the referred specialty services at the designated military hospital or clinic.

2. Who assigns my specialist?

If a military hospital or clinic accepts the specialty care referral, then it will schedule the visit with one of its specialists. If it can’t provide the care, we’ll assign you to a network specialty provider.

3. What if my military hospital or clinic can’t provide the specialty care?

We’ll assign you to a network specialty provider. 

4. Will I automatically be assigned the specialist my primary care manager requests?

No. The local military hospital or clinic may review and override the referral selection.

5. If I don’t want the specialist I’m assigned, may I request someone else?

No. Once a military hospital or clinic accepts the referral, you can’t request specific specialists or request a change from TRICARE East. See the response to question 8.

6. What if I want a non-network provider?

Your referring provider must give a valid medical reason for referring you to a non-network specialist. If the choice is yours, you can use your point-of-service option.

7. What happens if I don’t follow the referral process?

If you choose your own specialist or get care from a specialist without following the requirements, the POS option applies to your care.

If you receive specialty care from a non-authorized TRICARE East provider, you’ll be responsible for all care costs.

8. May I call TRICARE East to change the assignment?

No. Once a military hospital or clinic accepts the care, TRICARE East can’t change the provider on the referral. Only the military hospital or clinic can do that and only under specific conditions.

9. Under what circumstances would TRICARE East consider my request for a different specialist?

We only bypass the specialty referral process for continuity of care for the same episode of care (not a new condition) to the same provider.