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
  • You can view authorization status, provider, and services authorized on the secure Beneficiary Self-Service portal.
• 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
  • You can view status of referrals, authorizations, and claims using the MyCare Overseas mobile app or web-based portal.
• TOL Patient Portal or MHS GENESIS
  • If you're registered on the TOL Patient Portal, you can view your referral details by:
    • Logging into the TOL Patient Portal
    • Clicking on Appointments
    • Clicking on My Referrals
  • 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:

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.

• 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 costs.