How Referrals Work With Your TRICARE Prime Plan > TRICARE Newsroom > Articles

Are you enrolled in a TRICARE Prime plan? Then you have a primary care manager (PCM) to manage your basic primary health care services. But what if you need specialist treatment, like a cardiologist to assess a possible heart problem or a dermatologist to check for a mole that has changed? In this case, your PCM should submit a recommendation for you to see a specialist.

Some TRICARE plans, including TRICARE Select, do not require referrals for most healthcare services. However, if you are enrolled in one of the following plans, you need a referral before seeing a specialist:

“If you are an active duty service member or active duty family member enrolled in a TRICARE Prime plan, you need a referral from your PCM to seek most specialty care,” Tonya Utterback said. , expert in reference and authorization of the TRICARE health plan at the Defense Health Agency. “Without a referral, you may not be able to make an appointment with a specialist, or TRICARE may not be able to pay for it.”

What else should you know about recommendations? Here are some helpful facts about referrals to get you started.

  • How long does the SEO process take? Your PCM will send a referral request to your regional contractor, who will process the referral. It may take approximately three business days for your regional contractor to process your referral. It may take less time if your PCM determines that your referral is “clinically urgent” and marks it as such.
  • How to track your SEO? You can view or check the status of your referral by logging into your account on your regional contractor’s website. If you are not already registered for Secure Services, you will need to register first and then log in. You can also call your regional contractor’s automated telephone service. If you are overseas, call your regional TRICARE Overseas Program call center or visit the MyCare Overseas app.
  • Where can you receive care? Your regional contractor can refer you to a military hospital or clinic or a TRICARE network provider. If a network provider is not available in your area, you may be granted permission to consult a non-network provider.
  • Can you consult a specialist without a referral? With the service point option, yes. The point-of-care option allows people enrolled in a TRICARE Prime plan to see a specialist without an approved referral from their PCM. But you will be subject to service point charges. As indicated in the 2022 TRICARE Costs and Fees Fact Sheet, an annual pre-cost-sharing deductible ($300 for individual/$600 for family) will come into effect under the point-of-service option. Service point option is not available for active duty members (ADSM). Civilian care from the ADSM must be done via a PCM referral, with the exception of emergency care.
  • Is a pre-authorization the same as a referral? It’s a little different than a referral, but it still involves getting approval from your regional contractor. Sometimes your TRICARE contractor needs to review a requested health care service or prescription drug to see if it is medically necessary and a benefit covered by TRICARE. This is called a pre-authorization. Some health care services require pre-authorization before you receive them, regardless of your TRICARE plan. These include complementary dental services, applied behavior analysis, home health care, palliative care, etc. Without this approval, you may be responsible for the full cost. ADSMs require prior authorization for all specialist inpatient and outpatient services.

Once the referral process is complete, you will receive an electronic authorization letter. Make an appointment with the health care provider listed on this letter. The authorization has an expiration date, so don’t wait too long. Want to use another provider? Then contact your regional contractor:

If you are still unsure whether you need a referral or pre-clearance, you can go to the Referrals and Pre-clearance page. If you seek mental health care, see the rules on the Getting Mental Health Care page.

Before seeking care from a specialist or anyone other than your PCM, make sure you are familiar with the rules of your health plan. Contact your TRICARE contractor if you have any questions.


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