Referral and Prior Authorization Requirements
Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends you to see a cardiologist to evaluate a possible heart problem.
The referral may be one of the following:
Evaluation only – Allows for two office visits with the specialist to evaluate the beneficiary, and perform diagnostic services, but not treat. This type of referral includes diagnostic/ancillary services that do not require HNFS approval.
Evaluation and treatment – Allows for one evaluation visit with the specialist and five follow-up visits. This type of referral includes subsequent care (diagnostic and ancillary services, related procedures) that does not require HNFS approval.
Procedure only – Allows for the test/procedure only.
Second opinion – Allows for one evaluation visit with the specialist and one follow-up visit.
Important Things to Remember about Referrals
- With an approval from HNFS, you may be directed to receive care at a military hospital or clinic.
- TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries must see TRICARE network providers when available. If a non-network provider is requested for a TRICARE Prime beneficiary and there are network providers available within access standards, then care may automatically be redirected to a network provider. In the rare case that network providers are not available or there is a clinically significant reason care must be provided by a non-network provider, clear and detailed documentation must be provided for consideration of this request.
- The Point of Service (POS) option allows TRICARE Prime beneficiaries to self-refer to any TRICARE network or non-network provider for medical/surgical or mental health services without referrals from their PCMs or HNFS. Beneficiaries who use the POS option will pay a deductible and have higher cost-shares for services. The POS option does not apply to active duty service members, so they may be responsible for the entire cost of care.
Prior authorizations for certain services and/or procedures require HNFS review and approval, prior to being provided. Some services and/or procedures that require approval include certain mental health care, hospitalization, surgical, and therapeutic procedures.
Note: Please review our Supplemental Health Care Program page for information on the active duty service member approval process.
HNFS requires authorization of inpatient facility admissions and notification of discharge dates by the next business day following the admission and discharge. HNFS conducts continued stay reviews for all mental health care and other services. Clinical records will be requested as necessary.
When are Both a Prior Authorization and Referral Required?
Prior authorization and a referral are both required when a TRICARE Prime, TRICARE Prime Remote or TRICARE Young Adult Prime beneficiary receives a referral to a specialist and the specialist wants to perform a service on the prior authorization list. For example, a PCM referral is needed to see a general surgeon, and a prior authorization is needed if the surgeon wants to perform weight loss surgery.
Prior Authorization, Referral and Benefit Tool
To determine if a service requires an approval from HNFS, use the Prior Authorization, Referral and Benefit Tool.