Referrals and Pre-Authorizations

A referral is when your Primary Care Manager (PCM) or provider sends you to another provider for care that they don’t provide.

A pre-authorization is when your care is approved by your regional contractor 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 must:

• Schedule 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 the assigned military hospital or clinic.

View My Referral or Pre-Authorization

You can also view this information on your Secure Patient Portal. You can also check the status of your pre-authorization online. 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, resulting in higher out-of-pocket cost.

Getting a Second Opinion

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

If you want a second opinion, go to your PCM and explain your situation and 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

If you’re an active duty service member, your PCM works with your regional contractor to get you a referral.

Active duty service members need a referral for urgent care treatment. For remotely located Active Duty and Reserve Component service members, the Military Medical Support Office (MMSO) at Defense Health Agency (DHA) - Great Lakes gives pre-authorization for civilian medical care.

Service Point of Contact 

You must have pre-authorization for all specialty care. All specialty care requests are referred from your regional contractor to your Service Point of Contact (SPOC). The SPOC will review all requests and determine if your health care requires a fitness-for-duty determination based on current service-specific guidelines and clinical standards. The SPOC will ensure your medical care related to your fitness-for-duty is covered.

Your SPOC will:

• Review requests for specialty and inpatient care to determine how it might affect your fitness-for-duty.
• Decide if you can get care at a military hospital or clinic or from a civilian provider.

Fitness for Duty Review 

• If the SPOC thinks that your condition may change your fitness-for-duty or that your condition requires a medical board, the SPOC will refer you to the closest military hospital or clinic that has the ability to provide the care and make a duty determination.
• If the SPOC thinks there is no impact on your fitness-for-duty, the SPOC will refer you to a civilian specialist for the care. As a rule, maternity care will be provided locally. The SPOC will provide an answer to your regional contractor within two working days of the request, or sooner for an urgent problem.
• Your commander also may request a military medical evaluation at his or her discretion.
• You may choose to obtain your specialty care in a military hospital or clinic at any time if that is your preference and your commander concurs.  Inform your regional contractor when coordinating your referral.

You cannot refer yourself to a military or civilian specialist.  If you seek nonemergency care from other sources without first contacting your PCM, you may be held financially responsible for the entire bill for those health care services

You will need a fitness-for-duty review for:

• Maternity care
• Physical therapy
• Mental health
• Family counseling
• Smoking cessation programs