TRICARE Q&A: What You Need to Know About Referrals, Authorizations
If you’re enrolled in a TRICARE Prime plan, at some point you may need specialty care that your primary care manager (PCM) can’t provide. In that case, he or she may refer you to a specialty provider. You may need a referral and pre-authorization from your PCM to seek care from a specialty provider, depending on your TRICARE health plan.
“If you use TRICARE Prime, your PCM may refer to you a specialist, like a cardiologist, dermatologist, or obstetrician,” said Tonya Utterback, referral and authorization expert with the TRICARE Health Plan at the Defense Health Agency. “This specialty provider may be located at your military hospital or clinic, or at a civilian clinic. Before you seek care from this specialist—or anyone other than your PCM—make sure you’re familiar with the referral process.”
Q: How do I know if I need a referral?
A: If you’re an active duty service member (ADSM) or non-ADSM enrolled in a TRICARE Prime plan, then you need a referral from your PCM to seek most specialty care with another provider. TRICARE Prime options include:
- TRICARE Prime
- TRICARE Overseas Program (TOP) Prime
- TRICARE Prime Remote
- TOP Prime Remote
- US Family Health Plan
Referrals aren’t required for most health care services under TRICARE Select. As outlined in the TRICARE Plans Overview, TRICARE Select beneficiaries aren’t required to have a PCM and can choose to see 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. DS for services covered by TRICARE without a referral. However, certain services always require pre-authorization. ADSMs need a referral for all nonemergency care from a civilian provider. This includes specialty care, mental health care and substance use disorder services.
Q: How do I get a referral?
A: You can contact your PCM. Your PCM will then work with your TRICARE contractor for the referral and/or authorization. Your contractor will try to refer you to a military hospital or clinic first. If that option isn’t available, the contractor will refer you to a network provider in your region. A specialist you have an approved referral to see can also submit referrals for care related to their specialty.
Q: What happens if I seek care without seeing my PCM first?
A: You may be responsible to pay out of pocket for care. If you’re enrolled in a TRICARE Prime plan and you visit a specialist without an approved referral from your PCM when it’s required, you’re using the point-of-service (POS) option and will be subject to POS charges. The POS option isn’t available for ADSMs.
Q: How do I check the status of my referral or authorization?
Q: What is pre-authorization?
A: Pre-authorization is when your TRICARE contractor reviews a requested health care service to see if it’s medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. and a TRICARE covered benefit. Certain services require pre-authorization before you receive them regardless of your TRICARE plan. These include hospice care, Applied Behavior Analysis, home health care, adjunctive dental services, and more. In many cases, your provider will contact your TRICARE contractor to get pre-authorization. ADSMs need pre-authorization for all inpatient and outpatient specialty services.
Q: After I get authorization, what steps do I take?
A: Your regional contractor (TRICARE East or TRICARE West) will send you and your provider an electronic authorization letter with instructions. Schedule your appointment with the provider listed in the letter. Note the expiration date of the authorization, and be sure to get care before it expires. If you need to find another provider, contact your regional contractor.
Q: I’m enrolled overseas. How do I request a referral and pre-authorization?
Take the time to learn about referrals and pre-authorizations and follow the rules of your health plan. This way, you can take command of your health and get the care you need. If you have questions, be sure to reach out to your TRICARE contractor.
Last Updated 10/14/2021