Referrals and Pre-Authorizations

A referral is when your primary care manager or provider sends you to another provider for care that they don’t provide.

A pre-authorization is when your regional contractor approves your care before you go to your appointment. If you are being referred, your provider will get you a referral and pre-authorization at the same time.

When care is approved:

Your regional contractor sends you an authorization letter with specific instructions. You can find this letter in your region’s patient portal.

You must:

• Book your appointment with the provider listed in the authorization letter. If you need to find another provider, contact your regional contractor.

• Get care before the authorization expires. Otherwise, you’ll need to get the care re-approved.

Note: Active duty service members need a referral for most care received outside of their assigned military hospital or clinic.

View My Referral or Pre-Authorization

You can view and check the status of your referral or pre-authorization in your regional contractor’s secure patient portal. You’ll need to create an account if you don’t have one.

Services That Don’t Require Referrals

Are you enrolled in a TRICARE Prime plan?

You can get the following services from a TRICARE network provider in your region without a PCM referral:

• Preventive services
• Outpatient mental health care visits

If you get care from a non-network provider (or a network provider outside of your region) without a referral from your PCM, you’re using the point-of service-option. You’ll have higher out-of-pocket costs when you use the point-of-service option.

Getting a Second Opinion

You have every right to request a second medical opinion from another provider. You, your PCM, or your regional contractor may request a second medical opinion.

If you want a second opinion, go to your PCM. Explain your situation and ask any questions you may have about the first specialist’s suggested care. Then, ask your PCM to coordinate a referral to another specialist and request a referral from your regional contractor, if necessary.

Network vs. Non-Network Providers

You should try to see network providers instead of non-network providers. Network providers can’t:

• Ask you to sign a document to make you pay for authorized services
• Ask you to sign a document to make you pay for any part of the service TRICARE doesn’t cover
• Refuse to see you because you won’t sign such a document

Active Duty Service Members

Are you an active duty service member? If so, your PCM works with your regional contractor to get you a referral. You need a referral for your urgent care treatment.

Remote Active Duty Service Members

Are you remotely located? Your civilian PCM will send your specialty referral to your regional contractor.

Usually, your regional contractor will review it and authorize continued civilian care. This decision is based on:

• Your active duty eligibility
• Medical necessity
• If TRICARE covers the requested service

In some cases, the Specified Authorization Staff may review your referral or authorization. The SAS is part of the Military Medical Support Office at Defense Health-Agency—Great Lakes.

For example, if you’re admitted to a civilian medical facility, the SAS will:

• Authorize your inpatient stay
• Notify your service to make sure your care is monitored and supported

Sometimes, the SAS may decide that a military hospital or clinic should treat your condition. In these cases, they’ll redirect your care there. Your regional contractor will:

• Let you know that SAS redirected your care
• Tell you how to access the military hospital or clinic and make an appointment

Note: You should arrange medical travel temporary duty assignment through your command. Active duty Air Force members should process their TDY at the closest Air Force military hospital or clinic.

Your commander may request a military medical evaluation at their discretion.

Looking to get specialty care at a military hospital or clinic? You can choose to do so, if your commander agrees. Let your regional contractor know when coordinating your referral.