Referrals and Pre-Authorizations

A referral is when your primary care manager (PCM) or provider sends you to another provider for care that he/she doesn’t provide.

If you’re an active duty service member enrolled in TRICARE Prime, your PCM works with your regional contractor for the referral.

Note: 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.

Getting pre-authorization means you’re getting the care approved by your regional contractor before you go to an appointment and get the care. If you have a referral, then your provider gets pre-authorization at the same time.

When care is approved:

Your regional contractor sends you an authorization letter with specific instructions. You can also view these instructions 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.

  • TRICARE East Region
  • TRICARE West Region
    • You can view authorization status, determination letters, and make network-to-network provider changes on the TRICARE West secure patient portal.
  • TRICARE Overseas
  • TOL Patient Portal or MHS GENESIS
    • If you're registered on the TOL Patient Portal, you can view your referral details by:
    • If you have a question about your referral, use TOL Secure Messaging to contact your care team.
    • If you're registered on the MHS GENESIS Patient Portal, you won't see the status of your referral. Referral authorization information isn't available on the MHS GENESIS Patient Portal. You'll need to check your region's secure patient portal.
  • Schedule your appointment with the provider listed in the authorization letter. Contact your regional contractor if you need to find another provider.
  • You must get care under the authorization before it expires, or you’ll need to get the care re-approved.

Learn more about the differences between a referral and pre-authorization below:

What plan are you using? Need a referral?
 Need pre-authorization?
TRICARE Prime (active duty service member) 

Yes, for any care your PCM doesn't provide (urgent, routine, preventive, and specialty care)

Your PCM works with your regional contractor for the referral.

If you get care without a referral, you’ll pay out-of-pocket.

Enrolled overseas? Call your regional call center.

Yes, for all specialty care.

You also need a fitness-for-duty review for certain care.

TRICARE Prime (all beneficiaries except active duty service members)

Yes, for specialty care and some diagnostic services.

Your PCM works with your regional contractor for the referral.

If you see a specialist without a referral, you’re using the point-of-service option.

Enrolled in TRICARE Prime Remote? Work with your regional contractor if you don't have an assigned PCM.

Enrolled overseas? Call your regional call center.

Yes, for all specialty care.

Your PCM gets your referral and pre-authorization at the same time.

All other TRICARE plans

  • TRICARE Select
  • TRICARE Select Overseas
  • TRICARE Reserve Select
  • TRICARE Retired Reserve
  • TRICARE For Life
  • TRICARE Young Adult-Select
No. Only Applied Behavioral Analysis requires a referral.

Need urgent care? >>Learn more.

Enrolled in the US Family Health Plan? You'll get a referral to a specialist from your designated provider.

You need pre-authorization for the following services:

Check with your regional contractor for additional requirements and specific processes:

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

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.

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.

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 costs.

 

 

What is Right of First Refusal?

This is when your regional contractor refers you to a military hospital or clinic first. The military facility has the right to take the referral or refuse it. If they refuse it, then you'll get a referral to a network provider.

Last Updated 3/8/2022