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.