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News | March 18, 2024

Unlock Your Health by Understanding the Referral Process

By Military Health System Communications

With TRICARE Prime, you get most of your routine health care from your primary care manager (PCM). But sometimes, you may need 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.
 
How referrals work
A referral is when your PCM or provider sends you to get care from another provider. This typically happens when you need specialty care. Your provider starts the process by sending a referral request to your regional contractor for review. In our area, the regional contractor is Humana Military for the TRICARE East Region. Once they approve your referral, Humana Military will post an authorization letter to your secure patient portal.
 
Referrals have expiration dates, so make sure you schedule your appointment before your referral expires. You can find the expiration date on your authorization 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 of calling our Integrated Referral Management and Appointing Center (IRMAC) at 855-227-6331.
 
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 non-emergency 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 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.
  • TRICARE For Life: You don’t need a referral for most health care services. But you may need pre-authorization for certain services.

When you don’t need a referral
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.
 
Active duty service members should get a referral for all non-emergency care their PCM doesn’t provide.
 
But all others with TRICARE Prime don’t need a referral for preventive care, urgent care, and most outpatient mental health care.
 
Whenever possible, seek care from your military hospital or clinic. For urgent care, we have three Urgent and Emergent Care Centers in the NCR. These are located at Dumfries Health Center, Fairfax Health Center, and Malcolm Grow Medical Clinics and Surgery Center.
 
Second opinions
You have the right to request a second medical opinion. Talk to your PCM to discuss your concerns about the referred care you received. Then, your PCM can request a referral to another specialist, if needed.
 
To learn more about referrals, visit TRICARE Referrals and Pre-Authorizations.
 
Need to Update Your Information in DEERS? Click Here