A referral is when your Primary Care Manager (PCM) or provider sends you to another provider for care that they don’t provide.
A pre-authorization is when your care is approved by your regional contractor before you go to your appointment. If you are being referred, your provider will get you a referral and pre-authorization at the same time.
When care is approved:
Your regional contractor sends you an authorization letter with specific instructions.
You must:
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Schedule your appointment with the provider listed in the authorization letter. If you need to find another provider, contact your regional contractor.
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Get care before the authorization expires, otherwise, you’ll need to get the care re-approved.
Note: Active duty service members need a referral for most care received outside of the assigned military hospital or clinic.
| What plan are you using? | Need a referral? | Need pre-authorization? |
| TRICARE Prime (active duty service member) | Yes, for any care your PCM doesn't provide (urgent, routine, preventive, and specialty care) Your PCM works with your regional contractor for the referral. If you get care without a referral, you’ll pay out-of-pocket. Enrolled overseas?Call yourregional call center. | Yes, for all specialty care. You also need afitness-for-duty reviewfor certain care. |
| TRICARE Prime (all beneficiaries except active duty service members) | Yes, for specialty care and some diagnostic services. Your PCM works with your regional contractor for the referral. If you see a specialist without a referral, you’re using thepoint-of-service option. Enrolled in TRICARE Prime Remote?Work with your regional contractor if you don't have an assigned PCM. Enrolled overseas?Call yourregional call center. | Yes, for all specialty care. Your PCM gets your referral and pre-authorization at the same time. |
| All other TRICARE plans
| No. OnlyApplied Behavioral Analysisrequires a referral. Need urgent care?>>Learn more. Enrolled in the US Family Health Plan?You'll get a referral to a specialist from your designated provider. | You need pre-authorization for the following services:
Check with your regional contractor for additional requirements and specific processes: |
View My Referral or Pre-Authorization
You can also view this information on your Secure Patient Portal. You can also check the status of your pre-authorization online. You’ll need to create an account if you don’t have one.
| Secure Patient Portal | Instructions |
| MHS GENESIS Patient Portal | MHS GENESIS Patient Portal, you won't see the status of your referral. Referral authorization information isn't available on the MHS GENESIS Patient Portal. You'll need to check yourregion's secure patient portal. |
| If you're registered on theTOL Patient Portal, you can view your referral details by:
If you have a question about your referral, use TOL Secure Messaging to contact your care team. | |
| TRICARE East Region | You can view authorization status, provider, and services authorized on the secureBeneficiary Self-Service portal. |
| TRICARE West Region | You can view authorization status, determination letters, and make network-to-network provider changes on the TRICARE Westsecure patient portal. |
| TRICARE Overseas | You can view status of referrals, authorizations, and claims using theMyCare Overseas mobile apporweb-based portal. |
Services that Don’t Require Referrals
Are you enrolled in a TRICARE Prime plan?
You can get the following services from a TRICARE network provider in yourregionwithout a PCM referral.
- Preventive services
- Outpatient mental health care visits
If you get care from a non-network provider (or a network provider outside of yourregion) without a referral from your PCM, you're using thepoint-of service-option, resulting in higher out-of-pocket cost.
Getting a Second Opinion
You have every right to request a second medical opinion from another provider. You, your primary care manager (PCM), or your regional contractor may request a second medical opinion.
If you want a second opinion, go to your PCM and explain your situation and any questions you may have about the first specialist’s suggested care. Then, ask your PCM to coordinate a referral to another specialist and request a referral from your regional contractor, if necessary.
Network vs. Non-Network Providers
You should try to see network providers instead of non-network providers. Network providers can't:
- Ask you to sign a document to make you pay for authorized services
- Ask you to sign a document to make you pay for any part of the service TRICARE doesn't cover
- Refuse to see you because you won’t sign such a document
Active Duty Service Members
If you’re an active duty service member, your PCM works with your regional contractor to get you a referral.
Active duty service members need a referral for urgent care treatment. For remotely located Active Duty and Reserve Component service members, theMilitary Medical Support Office (MMSO) at Defense Health Agency (DHA) - Great Lakesgives pre-authorization for civilian medical care.
Service Point of Contact
You must have pre-authorization for all specialty care. All specialty care requests are referred from your regional contractor to your Service Point of Contact (SPOC). The SPOC will review all requests and determine if your health care requires a fitness-for-duty determination based on current service-specific guidelines and clinical standards. The SPOC will ensure your medical care related to your fitness-for-duty is covered.
Your SPOC will:
- Review requests for specialty and inpatient care to determine how it might affect your fitness-for-duty.
- Decide if you can get care at amilitary hospital or clinicor from acivilian provider.
Fitness for Duty Review
- If the SPOC thinks that your condition may change your fitness-for-duty or that your condition requires a medical board, the SPOC will refer you to the closest military hospital or clinic that has the ability to provide the care and make a duty determination.
- If the SPOC thinks there is no impact on your fitness-for-duty, the SPOC will refer you to a civilian specialist for the care.As a rule, maternity care will be provided locally. The SPOC will provide an answer to your regional contractor within two working days of the request, or sooner for an urgent problem.
- Your commander also may request a military medical evaluation at his or her discretion.
- You may choose to obtain your specialty care in a military hospital or clinic at any time if that is your preference and your commander concurs. Inform your regional contractor when coordinating your referral.
You cannot refer yourself to a military or civilian specialist. If you seek nonemergency care from other sources without first contacting your PCM, you may be held financially responsible for the entire bill for those health care services
You will need a fitness-for-duty review for:
- Maternity care
- Physical therapy
- Mental health
- Family counseling
- Smoking cessation programs
What is Right of First Refusal?
This is when your regional contractor refers you to a military hospital or clinic first. The military facility has the right to take the referral or refuse it. If they refuse it, then you'll get a referral to a network provider.
Looking to book an appointment online at a military hospital or clinic? Visit the Secure Patient Portalfor more information.
Service Point of Contact Information
- Department of Defense SPOCs (Army, Air Force, Navy, & Marine Corps) are located at theMilitary Medical Support Office (MMSO) at Defense Health Agency, Great Lakes.
- U.S. Public Health Service and National Oceanic and Atmospheric Administration SPOCs are located at the Medical Affairs Branch of the Office of Commissioned Corps Support Services.
- U.S. Coast Guard personnel should call the Coast Guard Benefits Line.
Last Updated 3/4/2024
