What is a referral in TRICARE?

A referral in TRICARE is a formal authorization from a primary care manager (PCM) that directs a TRICARE Prime enrollee to receive care from a specialist or another provider. Under TRICARE Prime, referrals are required for most specialty care, and obtaining services without a proper referral can result in point-of-service charges, which are significantly higher out-of-pocket costs. The PCM evaluates the patient's condition and determines whether specialty care is medically necessary, then submits the referral through the TRICARE system. Referrals typically specify the type of specialist, the number of authorized visits, and the timeframe for the referral. TRICARE Select does not require referrals, as beneficiaries can directly access any TRICARE-authorized provider. Emergency care never requires a referral regardless of plan type. Some services under Prime also do not require referrals, including preventive care, mental health care (first eight outpatient visits), and care at military treatment facilities. Beneficiaries should verify their referral status before scheduling specialist appointments to avoid unexpected charges.