FALLS CHURCH, Va. – If you have a TRICARE Prime plan, referrals play a big role in how you get health care. A referral is when your primary care manager sends you to see another provider. If your PCM needs to refer you to a civilian provider, your TRICARE regional contractor also plays a role in the referral process.
“When you need a referral to get civilian care, your PCM sends a request to your regional contractor for review,” said Tonya Utterback, referral management expert with the TRICARE Health Plan at the Defense Health Agency. “Once your regional contractor approves the request, you’ll get an electronic authorization letter with instructions for using your referral.”
Read on to learn tips for finding and using your referrals.
Where to find your referral
It typically takes three business days for your contractor to process your referral. To check its status or download your authorization letter, go to your regional contractor’s patient portal. If you don’t already have an account for your region’s portal, you’ll need to create one.
You can also get information about your referral by phone.
What to do with your referral
Your authorization letter will outline the care and number of visits you’re approved for. It will also have information about the provider you’re referred to. Contact that provider to schedule your first appointment. If you want to see a different provider, call your regional contractor.
Don’t forget to check the letter for your referral’s expiration date. Most referrals expire in 180 or 365 days. If your referral expires and you need a new one, contact your PCM.
When you need a referral
Do you need a referral? It depends on your beneficiary category, health plan, and the type of care you need:
- Active duty service members: You need a referral for any medical care your PCM doesn’t provide. If you get care without a referral, you may have to pay out of pocket.
- All others with a TRICARE Prime plan: You need a referral for specialty care and some diagnostic services. 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, as outlined in the TRICARE Costs and Fees Fact Sheet.
- TRICARE Select, TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE For Life: You don’t need a referral for most health care services.
To learn more about referrals, check out Referrals and Pre-Authorizations and “Q&A: Getting and Using Referrals With TRICARE.” To learn how to make an appointment with your PCM, go to Book Appointments.
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