What You Need To Know About Referrals and Authorizations (East Region)

11/5/2024

This article contains information specific to beneficiaries living in the East Region. Check the map to find your region.

Sometimes, healthcare terms can be confusing as you try to understand the coverage of your health plan. Do you know the difference between a referral and a pre-authorization? It’s important to know which each term is, as you may need one as a beneficiary to seek and get the health care you need. Here are some of the most asked questions and answers about referrals and authorizations.

1. What is the difference between a referral and pre-authorization?

A referral is when your primary care manager sends you to another provider for care. If you have TRICARE Prime and see a provider other than your PCM for non-emergency care without a referral, you will pay more.

A pre-authorization is a review of a requested healthcare service to see if the care will be covered by TRICARE. Humana Military does this review for the East Region. Check for services that need pre-authorization at TRICARE.mil.

2. How do I know if I need a referral?

Whether or not you need a referral depends on who you are and in which TRICARE plan you are enrolled:

• Active duty service members: Yes, most care not provided by your PCM will require a referral.
• TRICARE Prime: Yes, for specialist office visits and some diagnostic services. Certain services (e.g., inpatient admissions, some behavioral health services, adjunctive dental careDental care you need to treat a covered medical condition, injury, or disease., home health services, etc.) require pre-authorization.
• TRICARE Prime Remote: Yes, for all services that your assigned civilian PCM can’t perform.
• TRICARE Select: No, a referral isn’t required for services.

3. What are some categories of services that require referrals or pre-authorization?

Certain services, such as inpatient admissions, some behavioral health services, adjunctive dental care, and home health services require pre-authorization. Check for services that need pre-authorization on tricare.mil.

IMPORTANT NOTE: Benefits within the Autism Care Demonstration require a referral and continued authorizations. Find out more about the Autism Center of Excellence.

4. Do I need a referral for emergency care?

No! Don’t delay seeking necessary or emergent care when needed. Emergency care through an emergency roomThe hospital department that provides emergency services to patients who need immediate medical attention. at a hospital for a true emergency doesn’t require a referral. Learn more about where to go for emergency care as a TRICARE beneficiary.

5. How do I get a referral?

TRICARE Prime enrollees will need to contact their assigned PCM for a referral to avoid point-of-service charges.

TRICARE Select enrollees don’t require a referral; however, authorizations may be required for services outside of a physician’s office.

6. How do I check the status of my referral or authorization?

You can access your referral letters by logging into your self-service account. When you view a referral that has been processed, you’ll find a link to view your referral letter. It could take up to 48 hours for a referral to show once a doctor has submitted it. It may take up to five days for an authorization to show in your account.

7. What do I do next when I get an authorization letter?

As soon as possible, make an appointment with the provider or specialist listed in the letter. Each authorization letter will list an expiration date. You need to schedule your appointment before that date, or you’ll need to be re-approved.

If you have specific questions about an authorization or referral, log in to your secure self-service account and speak with an agent between Monday and Friday, 8 a.m. to 6 p.m. Or you can send a secure message at any time of the day.