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Seeking Referrals or Prior Authorizations for Specialty Care with TRICARE

5/24/2018

At some point, you may need specialty care that your primary care manager (PCM) or general physician can’t provide. He or she may refer you to a specialty provider, like a cardiologist, dermatologist or obstetrician. Under some TRICARE programs, you may need a referral or prior authorization from your PCM to seek care from a specialty provider.

A referral is when your PCM or provider sends you to another provider for care. You may also need pre-approval, or prior authorization, for coverage of certain care. Prior authorization is a review of a requested health care service by your regional contractor to see if TRICARE will cover it.

Under TRICARE Prime, your PCM provides your routine care. When specialty care is needed, you’ll generally need to coordinate with your PCM (or other care coordinator) to see a specialty provider. Under the new rules for TRICARE Prime, your PCM may refer you to a network specialist without approval from your regional contractor. For clinical preventive services, TRICARE Prime beneficiaries can see any network provider within their region. You don’t need a referral or authorization.

Without a referral from your PCM, you can get care from any 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., but you’ll pay more out of pocket. Your claim will be subject to the point-of-service (POS) option deductible and cost-share (50 percent of the TRICARE-allowable chargeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges.). POS doesn’t apply to active duty service members (ADSMs). POS doesn’t apply to clinical preventive care you get from a TRICARE network provider in your region.

ADSMs must get referrals for civilian care. This includes mental health care, specialty care and more. ADSMs also need prior authorizations for all inpatient and outpatient specialty services.

If you have TRICARE Prime and you live within a one-hour drive of a military hospital or clinic, your provider may refer you for specialty care at that facility. You may get travel reimbursement if referred for specialty care more than 100 miles away from your provider’s office.

There is no referral requirement for urgent care visits, except for ADSMs enrolled to a military hospital or clinic. POS deductibles and cost-shares don’t apply when you get urgent care from a TRICARE network provider or a TRICARE-authorized (network or non-network) urgent care center or convenience clinic. Referrals aren’t required for most services under TRICARE Select.

Under TRICARE Prime and TRICARE Select, certain services need prior authorization. Some providers may contact your regional contractor to get you prior authorization. Prior authorizations apply to services like:

Your PCM will work with your regional contractor for referrals and prior authorizations as needed. For more information, visit your regional contractor’s website and the Referrals and Authorization page on the TRICARE website.

Last Updated 7/31/2018