FALLS CHURCH, Va. –
Do you have
TRICARE Prime? If so, you likely get most of your routine healthcare from your
primary care manager. But sometimes, you may need specialty care that your PCM can’t provide. This is when your PCM will give you a
referral. Having a referral can reduce your out-of-pocket expenses. Referrals can also help reduce the time you need to wait to get specialty care.
“If you have TRICARE Prime, referrals are important because they help you get the right care from the right providers,” said Jacob Sanchez, referral management subject expert, TRICARE Health Plan, at the Defense Health Agency. “Knowing how they work makes it easier to access the services you need and get the most out of your TRICARE benefit.”
In this article, you’ll learn about the TRICARE Prime referral process.
How referrals work
Your provider starts the process by sending a referral request to your
regional contractor. They review the referral request and, once processed, send you a notification in your beneficiary self-service portal. Then, you can contact the provider listed on the notification letter to make your appointment.
When to get a referral
Do you need a referral? It depends on your beneficiary category, your TRICARE plan, and the type of care you need.
- Active duty service members: You need a referral for any nonemergency care your PCM doesn’t provide. This includes specialty care and urgent care. If you get care without a referral, you may have to pay out of pocket.
- All others with a TRICARE Prime plan: You don’t need a referral for preventive care, urgent care, or most outpatient mental healthcare. You do need a referral for specialty care and some diagnostic services, as described in the TRICARE Plans Overview Fact Sheet. If you get this care without a referral, you’ll be using the point-of-service option. You’ll pay more out of pocket if you use this option.
- TRICARE For Life: You don’t need a referral for most healthcare services. But you may need pre-authorization for certain services.
You don’t need a referral to get emergency care. However, you should contact your PCM the next business day after you get emergency care.
Other helpful referral tips
Second opinions
Do you have concerns or questions after seeing a specialist for care? Are you unsure about a diagnosis or treatment option? You have the right to request a
second opinion. With TRICARE Prime, you should request a second opinion through your PCM.
Referrals expire
Don’t forget that referrals have expiration dates. Make sure to schedule your appointment and get care before your referral expires. You can find the expiration date on your notification letter. If your referral expires and you need a new one, contact your PCM.
When you get a referral for specialty care, you can expect to get an appointment within 28 days.
Transferring referrals within and between regions
Are you moving to another location in the U.S.? Whether your sponsor has recently gotten permanent change of station orders, or you’re moving for personal reasons—there’s good news about moving with your TRICARE coverage. Your active referrals remain valid within the same region and automatically transfer between the East and West Region.
If you’re moving to a different region:
Do you have any active
referrals? Your referrals will still be valid in your new location. Your active referrals will automatically transfer to your new contractor once you change your enrollment and update the
Defense Enrollment Eligibility Reporting System with your new address.
Here are the steps you should follow:
- After your move, update your enrollment within 90 days. Log in to milConnect and choose Beneficiary Web Enrollment from the Benefits menu. Update your enrollment based on your new address, so that DEERS shows that you’re in your new location
- Contact your new regional contractor. Ask them to create a new specialty referral in your new location for the active specialty referrals that were transferred. This will help you continue your specialty care without delay.
- Your new contractor will generate new specialty referrals to a new specialty provider. This new referral will be based on your location, specialty you were referred to, episode of care, and the expiration date of your original referral. (Note: Your specialty referral may be assigned to a military hospital or clinic in your new location, if the military hospital or clinic is able to provide the care.)
- Call to schedule an appointment with the new specialty provider’s office.
- Call your new PCM to schedule an appointment. (Note: The referral transfer process is meant to avoid delays for specialty care while waiting to establish care with your PCM for new referrals. You should make an appointment with your new PCM as soon as possible.)
Contact your regional contractor with questions about referrals:
- West Region: 888-TRIWEST (874-9378)
- East Region: 800-444-5445
If you’re moving within the same region:
- After your move, update your enrollment within 90 days. Log in to milConnect and choose Beneficiary Web Enrollment from the Benefits menu. Your update will trigger the DMDC/DEERS Support Office to notify your regional contractor about your address change. NOTE: If you need help, contact your regional contractor.
- Call your regional contractor. Ask them to create a new specialty referral in your new location, to see a new specialist. (Note: Your specialty referral may be assigned to a military hospital or clinic in your new location, if the military hospital or clinic is able to provide the care.)
Do you or a family member get services through the Autism Care Demonstration or Extended Care Health Option? You should contact your new regional contractor to let them know. Once your new contractor identifies a new case manager, your previous case manager will work with your new one to ensure a warm handoff of services.
Unlock your health with knowledge that TRICARE has you covered. To learn more about referrals, visit TRICARE Referrals and Pre-Authorizations.
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