What's the difference between a referral and prior authorization?

Referrals and prior authorizations serve different purposes:

Referrals:

What They Are

• Authorization from PCM to see specialist
• Required for TRICARE Prime
• NOT required for TRICARE Select

When Needed (Prime Only)

• Specialist visits
• Some diagnostic tests
• Certain therapies
• Mental health providers

Not Needed For

• Emergency care
• Routine eye exams
• Routine dental (separate coverage)

TRICARE Select

• No referrals required
• Self-refer to specialists
• Greater flexibility

Prior Authorization:

What It Is

• Pre-approval for specific services
• Required for BOTH Prime and Select
• Ensures medical necessity

Services Requiring Prior Authorization

• Inpatient hospitalizations
• Some outpatient surgeries
• Durable medical equipment over $1,000
• Certain medications
• Home health care
• Some imaging (MRI, CT, PET scans)
• Sleep studies
• Physical therapy (after initial visits)

Who Handles It

• Usually your provider requests it
• TRICARE reviews medical necessity
• Approval or denial issued

Timeline

• Non-urgent: 14 days
• Urgent: 72 hours
• Emergency: Retroactive approval

If Denied

• Can appeal decision
• Provider can submit additional information
• Second opinion available

Key Differences:

Referrals

• Prime only
• From PCM to specialist
• For routine specialty care

Prior Authorization

• Both Prime and Select
• For specific high-cost services
• Proves medical necessity

What Happens Without Them:

No Referral (Prime)

• Services may not be covered
• You pay out-of-pocket
• Exception: emergencies

No Prior Authorization

• Claims may be denied
• You're responsible for costs
• Appeal process available

Best Practices

• Ask provider if authorization needed
• Verify approval before service
• Keep authorization numbers
• Check expiration dates

Your provider usually handles these processes, but it's good to understand your responsibilities.