If you have a Tricare insurance plan, there may come a time when you need specialty care that your general physician or primary care manager (PCM) does not provide. Therefore, under some Tricare programs, you will need a referral or prior authorization from your PCM before you can seek a health care service from a specialty provider.
A Tricare referral is when your provider or PCM sends you to a different provider for a health care service, and prior authorization means that you are getting the health care service approved by the regional contractor in your region before the appointment. If you need to see a specialty provider, your PCM will work with your regional contractor for both referral and prior authorizations as they are needed. However, you need to know when you need a referral and when you need prior authorization. You also need to know how to submit and review requests.
When do I need a TRICARE referral?
Getting a Tricare referral depends on who you are and your Tricare plan. If your PCM does not provide a health care service that you need, then he or she may need to give you a referral for you to see a specialty care provider that provides the needed service.
Note: If you are an active duty service member (ADSM), you do not need a referral for urgent care visits unless you are enrolled to a military hospital or clinic.
How to Get a TRICARE Referral
You may be wondering how to get a Tricare referral now that you know that one is needed. It is essential that you know that you cannot get any care if you have not yet seen your PCM. If you do, you will be responsible for paying all out-of-pocket expenses.
First, your PCM will work with your regional contractor to find a referral in your area. Next, the contractor will refer you to a military hospital or clinic. If neither is available, you will then be referred to a network provider in your region. You need to know that military hospitals and clinics have the right to refuse a referral. If this happens, then you will get a referral to a network provider.
For more information on Tricare referrals, download our comprehensive guide.
When do I need a TRICARE prior authorization?
There may come a time when getting a Tricare referral is not enough. Meaning, that you will also need to get prior authorization to get coverage for the specialty care.
According to Tricare, prior authorization is a review of a health care service request by your regional contractor to see if Tricare will cover the requested care. If you have a Tricare referral, then your provider will also get prior authorization at that time. However, if you are not required to get a referral, then you will need to know which services require prior authorization.
How to Get a TRICARE Authorization
If you are currently enrolled in a Tricare Prime Plan, then your PCM will work with your regional contractor to obtain prior authorization. For all other Tricare plans, you will need to contact your regional contractor. Through your regional contractor, you will be able to get a copy of the authorization form.
Which specialty care services require prior authorization?
Many Tricare plans require that you get Tricare authorization from your regional contractor before you make an appointment for specific services. These services include but are not limited to, applied behavior analysis for autism spectrum disorder, home health services, hospice care, and transplants.
If you are an ADSM, you must also get prior authorization for all specialty care, such as family counseling, maternity, and physical therapy. Also, you will need prior authorization for all inpatient and outpatient specialty services.
If you are another beneficiary enrolled in a Tricare Prime Plan, then you must have prior authorization for all special care services. Also, your PCM will get your referral and authorization at the same time. However, if you have a Tricare Prime Plan, then you do not need a referral for preventative services or outpatient mental health care visits.
How can I view my TRICARE referrals and prior authorizations?
You can view or check the status of your Tricare prior authorization form online through the Tricare website. You can also check the status of your Tricare referral form through the online portal.
First, you will need to go to your regional contractor’s website. If you have not done so already, you will need to register for secure services. Then, you will need to sign into your account. From there, you will be able to view or check your referrals and prior authorizations.
Find out everything you need to know about how to view a Tricare prior authorization by downloading our free guide.
What do I do when my TRICARE prior authorization is approved?
If your Tricare prior authorization is approved, your regional contractor will send you and your provider an authorized letter. In which, Tricare will detail specific instructions. Then, you can schedule an appointment with a provider listed in the authorized letter. If you need to find another provider, then you will need to contact your regional contractor.
It is crucial that you know that you must get care under the authorization before it expires. If you fail to do so, you will need to get the care re-approved.