Referrals and Pre-Authorizations

Note: Active duty service members need a referral for most care received outside of the assigned military hospital or clinic.

Learn more about the differences between a referral and pre-authorization below

What plan are you using?

Need a referral?

Need pre-authorization?

TRICARE Prime (active duty service member)

Yes, for any care your PCM doesn't provide (urgent, routine, preventive, and specialty care)

Your PCM works with your regional contractor for the referral.

If you get care without a referral, you’ll pay out-of-pocket.

Enrolled overseas? Call your regional call center .

Yes, for all specialty care.

You also need a fitness-for-duty review for certain care.

TRICARE Prime (all beneficiaries except active duty service members)

Yes, for specialty care and some diagnostic services.

Your PCM works with your regional contractor for the referral.

If you see a specialist without a referral, you’re using the point-of-service option .

Enrolled in TRICARE Prime Remote? Work with your regional contractor if you don't have an assigned PCM.

Enrolled overseas? Call your regional call center .

Yes, for all specialty care.

Your PCM gets your referral and pre-authorization at the same time.

All other TRICARE plans

• TRICARE Select
• TRICARE Select Overseas
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE For Life
• TRICARE Young Adult-Select

Need urgent care? >> Learn more.

Enrolled in the US Family Health Plan? You'll get a referral to a specialist from your designated provider.

You need pre-authorization for the following services:

• Adjunctive dental services
• Applied behavior analysis
• Home health services
• Hospice care
• Transplants (all solid organ and stem cell)
• All services covered under the
• Extended Care Health Option
• Some services covered under the Provisional Coverage Program

Check with your regional contractor for additional requirements and specific processes:

View My Referral or Pre-Authorization

You can also view this information 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.

Learn more about Secure Patient Portals below

Secure Patient Portal

Instructions

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.

  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 cost.

  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.

  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

  Active Duty Service Members

  Are you an active duty service member? If so, your PCM works with your regional contractor to get you a referral. You need a referral for your urgent care treatment.

  Remote active duty service members

  Are you remotely located? Your civilian PCM will send your specialty referral to your regional contractor.

  Usually, your regional contractor will review it and authorize continued civilian care. This decision is based on:

  • Your active duty eligibility
  • Medical necessity
  • If TRICARE covers the requested service

  In some cases, the Specified Authorization Staff may review your referral or authorization. The SAS is part of the Military Medical Support Office at Defense Health-Agency—Great Lakes.

  For example, if you’re admitted to a civilian medical facility, the SAS will:

  • Authorize your inpatient stay.
  • Notify your service to make sure your care is monitored and supported.

  Sometimes, the SAS may decide that a military hospital or clinic should treat your condition. In these cases, they’ll redirect your care there. Your regional contractor will:

  • Let you know that SAS redirected your care.
  • Tell you how to access the military hospital or clinic and make an appointment.

  Note: You should arrange medical travel temporary duty assignment through your command. Air Force active duty service members should process their TDY at the closest Air Force military hospital or clinic.

  Your commander may request a military medical evaluation at their discretion.

  Looking to get specialty care at a military hospital or clinic? You can choose to do so, if your commander agrees. Let your regional contractor know when coordinating your referral.

  What is Right of First Refusal?

  This is when your regional contractor refers you to a military hospital or clinic first. The military facility has the right to take the referral or refuse it. If they refuse it, then you'll get a referral to a network provider.

  Looking to book an appointment online at a military hospital or clinic? Visit the Secure Patient Portal for more information.

  Service Point of Contact Information
  • Department of Defense SPOCs (Army, Air Force, Navy, & Marine Corps) are located at the Military Medical Support Office (MMSO) at Defense Health Agency, Great Lakes.
  • U.S. Public Health Service and National Oceanic and Atmospheric Administration SPOCs are located at the Medical Affairs Branch of the Office of Commissioned Corps Support Services.
  • U.S. Coast Guard personnel should call the Coast Guard Benefits Line.