Referral
Quick Definition
Authorization from your PCM to see a specialist.
Video Explanation
Full Definition
A referral is formal authorization from your Primary Care Manager (PCM) for you to receive specialty care or certain services. Referrals are a key component of the TRICARE Prime managed care system and help ensure coordinated, medically necessary care.
When referrals are required: • TRICARE Prime: Required for most specialty care • TRICARE Select: Not required (you can self-refer) • Active Duty: Always required except for emergencies
What referrals authorize: • Visits to specialist providers • Diagnostic tests and imaging • Certain therapies and treatments • Number of approved visits • Timeframe for care
How referrals work: 1. Visit your PCM for evaluation 2. PCM determines specialist care is needed 3. PCM submits referral to TRICARE 4. You receive referral authorization 5. Schedule appointment with approved specialist 6. Specialist provides care within referral scope
Important notes • Referrals typically expire after a set time or number of visits • Some referrals include prior authorization for procedures • Emergency care never requires a referral • Self-referrals outside the system may not be covered
Referral management: • Track referrals through your online portal • Confirm referral is active before specialty appointments • Request extensions if more visits are needed • Keep PCM informed of specialty care outcomes
The referral system ensures your PCM stays informed about all your healthcare and helps prevent unnecessary or duplicate services, ultimately controlling costs while maintaining quality care.
Related Questions
What is the difference between TRICARE Prime and TRICARE Select?
TRICARE Prime is a managed care option with a primary care manager and lower costs. TRICARE Select offers more flexibility to choose providers with higher out-of-pocket expenses.
How do I find a TRICARE provider?
Use the online provider directory on your regional contractor's website or call them directly for assistance.
What's the difference between a referral and prior authorization?
Referrals allow you to see specialists (Prime requirement). Prior authorization is approval needed before certain services regardless of plan.
What is a Primary Care Manager (PCM)?
A PCM is your main doctor in TRICARE Prime who provides routine care, manages your health, and issues referrals for specialty care.
When do I need a referral for TRICARE?
TRICARE Prime requires referrals for specialty care outside your PCM. TRICARE Select does not require referrals to see any authorized provider.
Can I get a second opinion with TRICARE?
Yes, TRICARE covers second opinions for surgery or major procedures. Prime members need a referral, while Select members can self-refer.
What is the TRICARE Prime Demo program?
TRICARE Prime Demo is a pilot program launching in 2026 in Atlanta and Tampa. Managed by CareSource, it eliminates referral requirements and waives enrollment fees for participants.
Which states changed TRICARE regions in 2025?
In 2025, six states moved from the TRICARE East Region to the West Region: Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin.
Do I need a referral for mental health care with TRICARE?
TRICARE Prime requires a referral from your PCM for most mental health care. TRICARE Select allows direct access to network mental health providers without a referral.
What is TRICARE's policy on gender-affirming care?
TRICARE coverage for gender-affirming care is limited. Mental health counseling and hormone therapy may be covered, but surgical procedures are generally not covered for most beneficiaries.
Does TRICARE cover sleep apnea treatment?
Yes, TRICARE covers sleep apnea diagnosis and treatment including sleep studies, CPAP machines, oral appliances, and in some cases surgery.
Does TRICARE cover allergy testing and shots?
Yes, TRICARE covers allergy testing, allergy shots (immunotherapy), and allergy medications when medically necessary. Referrals may be required under TRICARE Prime.
How many physical therapy visits does TRICARE allow?
TRICARE does not impose a strict limit on physical therapy visits. However, continued treatment must be medically necessary, and authorization may be required for extended courses of care.
Does TRICARE cover dermatology and skin conditions?
Yes, TRICARE covers dermatology visits and treatment for medical skin conditions. Cosmetic procedures like elective mole removal and skin treatments for appearance only are not covered.
What substance abuse treatment does TRICARE cover?
TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, and medication-assisted treatment (MAT) for alcohol and drug use disorders.
Does TRICARE cover therapy?
Yes, TRICARE covers mental health therapy including individual, group, and family counseling with licensed providers. Referrals may be required under TRICARE Prime.
Does TRICARE cover allergy testing?
Yes, TRICARE covers allergy testing and treatment including skin tests, blood tests, and allergy immunotherapy (allergy shots) when ordered by a TRICARE-authorized provider.
Does TRICARE cover physical therapy?
Yes, TRICARE covers physical therapy when it is medically necessary and prescribed by a TRICARE-authorized provider. Some plans require a referral.
Does TRICARE cover speech therapy?
Yes, TRICARE covers speech-language pathology services when medically necessary for conditions such as speech disorders, language delays, swallowing difficulties, and stuttering.
Does TRICARE cover occupational therapy?
Yes, TRICARE covers occupational therapy when medically necessary to help patients regain daily living skills after injury, illness, or for developmental conditions.
Does TRICARE cover sleep studies?
Yes, TRICARE covers sleep studies (polysomnography) and home sleep tests when medically necessary for diagnosing sleep disorders such as sleep apnea.
Does TRICARE cover vasectomy?
Yes, TRICARE covers vasectomy as a covered surgical benefit. Standard copays and cost-shares apply based on plan type and provider network status.
Does TRICARE cover tubal ligation?
Yes, TRICARE covers tubal ligation (female sterilization) as a covered surgical and preventive care benefit with no cost-share for most beneficiaries.
Does TRICARE cover dermatology?
Yes, TRICARE covers medically necessary dermatology services including treatment for skin conditions, biopsies, and skin cancer screening. Cosmetic dermatology is not covered.
Does TRICARE cover podiatry?
Yes, TRICARE covers podiatry services for medically necessary foot and ankle conditions including treatment of diabetic foot care, fractures, and structural deformities.
Does TRICARE cover second opinions?
Yes, TRICARE covers second opinions from another qualified provider. Under TRICARE Prime, a referral may be needed; TRICARE Select allows direct access to another provider.
Does TRICARE cover substance abuse treatment programs?
Yes, TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, medication-assisted treatment, and intensive outpatient programs.
Does TRICARE cover TMJ treatment?
TRICARE covers TMJ (temporomandibular joint) disorder treatment including diagnostic evaluation, physical therapy, and oral appliances. Surgical treatment requires pre-authorization.
Does TRICARE cover tinnitus treatment?
Yes, TRICARE covers tinnitus evaluation and treatment including audiological assessment, hearing aids if hearing loss is present, and tinnitus retraining therapy.
What is TRICARE Prime?
TRICARE Prime is a managed care health plan similar to an HMO that provides comprehensive coverage with a primary care manager, low out-of-pocket costs, and referrals for specialty care.
What is a PCM in TRICARE?
A PCM (Primary Care Manager) is the healthcare provider assigned to TRICARE Prime enrollees who manages their overall care and provides referrals for specialty services.
What is a referral in TRICARE?
A referral in TRICARE is an authorization from your primary care manager (PCM) that allows you to see a specialist. Referrals are required under TRICARE Prime but not TRICARE Select.
What is a non-availability statement in TRICARE?
A non-availability statement (NAS) is a certification from a military treatment facility that a particular service is not available there, allowing the beneficiary to seek civilian care.
How to get a referral in TRICARE?
Request a referral from your primary care manager (PCM) during an appointment or by contacting your PCM's office. The PCM evaluates your need and submits the referral electronically.
How to get mental health care through TRICARE?
Access TRICARE mental health care by contacting your PCM for a referral (Prime), going directly to a network provider (Select), or calling the Military Crisis Line for emergencies.
How to get TRICARE authorization?
Your provider submits a pre-authorization request to TRICARE for services that require approval before treatment. The regional contractor reviews and responds within specified timeframes.
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