Does TRICARE Prime require referrals?

Asked by: Melyssa Roberts  |  Last update: February 11, 2022
Score: 4.4/5 (57 votes)

TRICARE Prime requires referrals for specialist office visits and some diagnostic services (if you receive services that require a referral without obtaining one, you are using your Point of Service (POS) option). Your PCM works with Humana Military for the referral and authorization.

Does TRICARE Prime need prior authorization?

All Other Beneficiaries Enrolled in a TRICARE Prime Plan

You must have prior authorization for all specialty care. Your primary care manager gets your referral and prior authorization at the same time.

Does TRICARE Prime require a referral for mammogram?

3-D screening or routine mammograms are covered as a preventive service. ... TRICARE Prime enrollees do not need a referral or authorization for breast cancer screenings, and have a $0 copayment when receiving services from any network provider. (Exception: Active duty service members require a referral.)

Does TRICARE Prime need a referral for Obgyn?

Beneficiaries Enrolled in a TRICARE Prime Plan

You must get a referral from your primary care manager (PCM) before seeking pregnancy care. You may not self-refer to an obstetrician or gynecologist even for your pregnancy. ... If not, your PCM will refer you to a network provider for the duration of your pregnancy.

What is not covered by TRICARE Prime?

In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-child care.


21 related questions found

Is TRICARE Prime the same as TRICARE for Life?

Once you have TFL, you're no longer eligible for TRICARE Prime, unless you're under the age of 65. ... “TRICARE For Life is an individual entitlement,” said Breslin. “That means coverage is only for the Medicare and TRICARE eligible beneficiary, and not for family members who aren't eligible for Medicare.”

What is the difference between TRICARE Prime and TRICARE?

With TRICARE Prime, your provider will file claims for you in most cases. Under TRICARE Select, you aren't required to have a PCM. You manage your own health care and can receive care from any provider. However, you can save money with TRICARE Select if you see a TRICARE-authorized network provider.

Which TRICARE plans require a referral?

A: If you're an active duty service member (ADSM) or non-ADSM enrolled in a TRICARE Prime plan, then you need a referral from your PCM to seek most specialty care with another provider. TRICARE Prime options include: TRICARE Prime. TRICARE Overseas Program (TOP) Prime.

Can I go to a civilian doctor with TRICARE Prime?

If you're looking for a doctor, TRICARE can help. ... You may get care from a provider at a military hospital or clinic or from a civilian TRICARE-authorized provider.

Where can I find TRICARE referrals?

Beneficiaries must log in at to view authorizations, referrals and individual Explanation of Benefits statements.

How long does it take to get a TRICARE referral?

Your specialty provider should be able to see you within 28 days, if they cannot, a patient should call Tricare and specialists will help locate a new provider for you.

Does TRICARE require a referral for psychiatrist?

You need to get a referral and prior authorization for all mental health care in the TRICARE network. You don't need it if you seek outpatient mental health services at a military hospital or clinic.

What is TRICARE Prime point of service option?

The Point of Service (POS) option allows those enrolled in TRICARE Prime (excluding active duty service members), TRICARE Prime Remote for Active Duty Family Members (TPRADFM) or TRICARE Young Adult Prime to receive care from a TRICARE-authorized health care provider other than their primary care manager (PCM), without ...

How do I get TRICARE Prime authorization?

What does it mean to get prior authorization?
  1. Your regional contractor sends you and your provider an authorization letter with specific instructions.
  2. Schedule your appointment with the provider listed in the authorization letter.
  3. Contact your regional contractor if you need to find another provider.

Does TRICARE require a referral for urgent care?

You don't need a referral. You can get urgent care from any TRICARE authorized urgent care center or network provider.

Does Medicare require referrals?

Often insurance companies require you to have a referral, which is a written order from your primary care doctor, before they'll pay for a specialist's care. While Medicare doesn't require referrals as a general rule, certain situations may require a specific order from your primary care provider.

Do most doctors accept TRICARE?

While nearly all doctors in those states were accepting new patients, more than half rejected Tricare beneficiaries. ... The majority receive care mostly from military doctors.

Is dental covered by TRICARE?

TRICARE covers adjunctive dental care. as part of the "medical" benefit. Dental coverage for diagnostic and preventive services, restorative services, orthodontics, oral surgery, endodontics and other non-medical services are provided under two different dental plans: TRICARE Active Duty Dental Program.

What type of health coverage plan is TRICARE Prime?

TRICARE Prime health plans are similar to a health maintenance organization (HMO) program. It generally features the use of military hospitals and clinics and substantially reduces out-of-pocket costs for authorized care provided outside military hospitals and clinics by TRICARE network providers.

Do I lose TRICARE Prime when I turn 65?

For example, this means your new TFL coverage at age 65 doesn't extend to family members. Your spouse younger than age 65 would remain eligible for TRICARE Prime or TRICARE Select until they turn age 65 and become eligible for Medicare Part A and Part B. ... Learn how Medicare affects your TRICARE coverage at age 65.

Is your military ID your insurance card?

Your Military ID is your insurance card and has all of the information that a provider needs to file a claim. The DoD number, benefits number or sponsor's social security number can be used when a policy number is requested.