TRICARE Prime beneficiaries select their doctor who is called their Primary Care Manager (PCM). The PCM becomes the beneficiary’s “medical manager” and assists the beneficiary in accessing other healthcare providers.
The TRICARE program was designed so that the first priority for referral for specialty care or inpatient care is to the local military medical treatment facility (MTF) or other MTFs in the military direct care system.
If treatment becomes necessary for the beneficiary that is outside the PCM’s scope of care, the PCM may refer the beneficiary to a specialist at the Kirk military treatment facility, or to another MTF in the military direct care system within established access to care standards. MTF-enrolled TRICARE Prime beneficiaries who cannot be accommodated through the military direct care system will be offered a referral for care within the TRICARE civilian participating provider network. Under exceptional circumstances, if care cannot be provided within the access standards from either the military direct care system or the provider network; the beneficiary may be offered a referral and authorization to seek care at an outside non-TRICARE participating civilian medical provider.
Except in cases of medical emergencies and certain services that may be self-referred, referrals to specialists require prior authorization by the beneficiary’s PCM.
TRICARE excludes or significantly limits the coverage for certain medical, surgical, and behavioral health care services and supplies that are not medically necessary for the diagnosis or treatment of a covered illness or injury or for the diagnosis and treatment of pregnancy or well-baby care. To read or get more information on these services and supplies that may not be covered or have coverage limitations check your TRICARE Prime Handbook or with your regional contractor. The TRICARE North Regional Contractor is Health Net, 1-877-874-2273, or on the web at www.healthnetfederalservices.com.
Referral/Authorization Processing Summary
Once your PCM offers a referral, a consultation order is prepared and given to the beneficiary (patient) who takes it to the Referral Management Center located on the first floor of Kirk US Health Clinic. A determination is made whether the service is available within the military direct care system and established access to care guidelines. Those beneficiaries who reside within a sixty (60) minute or less drive from their place of residence to an MTF that can provide the necessary specialty care; will be referred to that MTF. If the patient cannot be accommodated or is outside the access to care travel standards (greater than a 60 minute drive) than a referral to a local network provider will be offered to the beneficiary.
A network referral order is prepared for the TRICARE North Region Managed Care Support Contractor (Health Net Federal Services) to find the needed specialty within the TRICARE civilian participating provider network.
The patient is given the referral order and takes it to Health Net Federal Services (TRICARE North Liaison Office), also located on the first floor of Kirk US Health Clinic, just a few doors away from the Referral Management Center.
The TRICARE North Liaison Office then selects a network specialist along with any patient’s preference whenever that provider is in the network and access to care standards.
Upon selection of a specialist, a letter is provided the beneficiary authorizing care to the network and for setting-up the appointments. In addition, a letter is sent to the network specialist authorizing that specialist to evaluate and/or treat, as appropriate.
The evaluate and treat referral is usually valid for one diagnosis per specialty and expires in six (6) months or six (6) visits which ever is first. The evaluate only referral is usually valid for one diagnosis per specialty and expires in six (6) months or one (1) visit which ever comes first.