TRICARE Prime beneficiaries need to know about both referrals and authorizations. If you are using TRICARE Standard or Extra, you don't typically need a referral for routine or specialty care, but there are some instances when you do need to get prior authorization so you don't have to pay for services.
First, let's review some terms:
- Referral: Where a primary care manager (PCM) or provider identifies a need for specialty care or services.
- Authorization: The determination that the requested service is:
- Medically necessary
- Delivered in the appropriate setting
- A TRICARE benefit
- Cost-shared by DoD through its contract
Next, let's look at the referral process. Referral Management happens when a PCM refers you for services outside of the PCM's capability to provide needed care (diagnostic tests, outpatient surgery, home health care, etc.). The PCM decides what type of provider you should see, for how long and for what services. The need for a referral may vary if you are enrolled to a Military Treatment Facility (MTF) or civilian network provider. In general, the following steps apply if you are enrolled to a network provider and may explain the time needed for you to get an authorization:
1. The PCM submits the referral.
2. The regional contractor works with the local MTF to determine if it can meet your health care needs.
- If the MTF can provide the service, it has one business day to decide if it has the capacity to see you.
- If the MTF can't provide the service, the referral goes back to the contractor, who then determines the appropriate network specialty care provider. For example, what specialist should the beneficiary see? Can the care be authorized?
3. When the referral goes back to the contractor, the contractor checks for availability of network providers within one-hour travel time from the beneficiary's residence.
a. If a network provider is available, you will be able to see them.
b. If a network provider is not available, the contractor works with other TRICARE-network or authorized providers to arrange for your care. 4. The contractor then issues a letter to you and the specialty provider listing the medical services you are authorized to receive.
|TRICARE For Life||
No referrals. Some services need prior authorization.
Be sure to follow Medicare rules.*
|Authorization required sometimes when Medicare-covered services are exhausted and or services are not covered and TRICARE is primary payer. Be sure to follow Medicare rules.*||For more information, visit www.tricare4u.com Or call WPS TRICARE For Life at 866-773-0404. For more information on Medicare rules, visit http://www.medicare.gov/Default.asp or call 800-MEDICARE.|
|TRICARE Standard and Extra||No referrals. Some services need prior authorization.||Your provider must request prior authorization from your regional contractor, when needed.||For more information, visit This page|
TRICARE Prime members who are:
You are authorized up to two urgent care visits each fiscal year (October 1 - September 30) without a referral or authorization from your PCM. You can visit any TRICARE-authorized provider.
Urgent care is care you need for a non-emergency illness or injury. You need urgent care treatment within 24 hours, and you shouldn't have to travel more than 30 minutes for the care. You typically need urgent care to treat a condition that:
Examples may include things like a high fever or sprained ankle. Urgent care is different than emergency care.
If you are unsure if you need urgent care, you can call the Nurse Advice Line at 1-800-TRICARE (800-874-2273), option 1
If you get a pre-authorization from the Nurse Advice Line for urgent care, it won't count against your two visit limit.
After you meet the two visit limit each fiscal year, you must have a referral from your PCM for any urgent care they can't provide.
Without a referral, you'll be using the point-of-service option.
After your urgent care visit, you should:
If you see another provider for urgent care for follow-up care without a referral, it will count against the two visit limit.
Referrals needed from your Primary Care Manager for specialty care services. Without a referral you pay higher out-of-pocket costs (point of service option).
Your PCM coordinates the referral through the MTF or regional contractor, who finds a specialty provider for you.
You and the specialty provider receive letters listing the services you are authorized to receive.
|Your PCM will request prior authorization from your regional contractor when needed.||
Or call - North Region, Health Net 877-TRICARE - West Region, UHC 877-988-9378 - South Region, Humana 800-444-5445
*Keep in mind that you must adhere to Medicare procedures to ensure proper coverage from both Medicare and TRICARE.
The contractor tracks this information to ensure submitted claims are authorized for payment. If your provider does not provide complete information on the referral request, it may be returned to your PCM for more information, slowing the process.
Remember, some doctors may have excellent intentions by referring you to a specialist, but you both need to make sure that the service is a covered benefit and the specialist is a network/authorized provider.
Be aware there some services require a separate, prior authorization review. Be sure an authorization is in place so you don't have to pay for the services out of pocket. You can check on your authorization by calling your regional contractor found at the TRICARE Contact Us web page.