Referral and Authorizations

If you’re enrolled in a TRICARE PRIME plan, at some point you may need specialty care that your primary care manager (PCM) can’t provide.  In that case, he or she may refer you to a specialty provider.  You may need a referral and pre-authorization from your PCM to seek care from a specialty provider, depending on your TRICARE health plan.
 
Don’t forget to keep your family’s information up-to-date in DEERS or call 1-800-538-9552
 
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Find TRICARE Options that Fit Your Health Care Needs

Health services come in many forms.  Sometimes it means going to your doctor for a routine checkup.  Other times it means getting care from a specialty provider, like a dermatologist or cardiologist.  But what if you need care for an extended amount of time?  While TRICARE doesn’t cover long-term care it does cover other specialty care services you may need to support your unique health care needs. 

• Benefit Updates

Common Referrals for Preventive Services at NHCA

Mammograms, TRICARE covers annual (every 12 months) mammograms for:  All women age 40 or older.  Women age 30 or older who are at a 15% or greater lifetime risk of developing breast cancer.  TRICARE covers 3D mammograms (digital breast tomosynthesis) for diagnostic purposes.

Well Woman Exams are covered annually for women under age 65.  These include breast exams, pelvic exams and Pap smears as needed.  TRICARE covers these exams with no cost-share or copayment. 
 
Eye Exams for Active Duty Family Members:  You can get one routine eye exam, per year from any TRICARE-authorized optometrist, no referral needed.  Retirees and Retiree Family Members can get a routine eye exam every two years.
 
Urgent Care:  Urgent care is care you need for non-emergency illness or injury, examples may include things like a high fever or sprained ankle. 
 
Nurse Advice Line:  If it’s after clinic hours or you’re not sure if you need to see a doctor, call TRICARE’s Nurse Advice Line 24/7.  Call 1-800-TRICARE (874-2273) – Option 1 to talk to a registered nurse.  Active Duty Service Members still need a referral for urgent care.  However, under TRICARE PRIME, Active Duty Family Members and Retiree and Retiree Family Members do not need a referral. 
 
Emergency Care:  What’s an Emergency?  A medical emergency is defined as the sudden and unexpected onset of a medical condition that is threatening to life, limb or eyesight, requires immediate medical treatment or manifests painful symptoms that require immediate response to alleviate suffering. If you are TRICARE PRIME you can go to the nearest emergency room for care, we ask that you follow-up with your primary care manager within 24 hours or when deemed appropriate.   

Referral Process

Step 1: Obtain a referral from your  Primary Care Manager. (PCM)
Step 2: Wait 48 business hours 
Step 3: Call 1-855-CAPMED1 (227-6331)     
You will be connected to Centralized  Appointment Center for the National Capital Region. (NCR)
Step 4: The clerk will assist you with booking your specialty care referral  at one of our  Military Treatment Facilities (MTF).
 
Note:   1) Per the TRICARE Prime benefit directive the location of your appointment will be no more then a 60 minute drive from your home (excluding traffic).
            2) If you are offered an appointment more than 28 days from the date you called, you may request the clerk forward your  referral to the Integrated  Referral Management Center (IRMAC).
            3) You do have the right to waive the 28 day access to care policy. If you do not waive, your referral will be forwarded to TRICARE, HUMANA MILITARY SERVICES, our Managed Care Support Contractor for the East Region. They will assign you to a civilian Specialty care network provider, based on your zip code. You will receive a letter in the mail within 7 to 10 business days with your authorization information. You may also go online to www.humanamilitary.com to access your authorization sooner!   
            4) If NO letter is received by the 10th business day, you can contact HUMANA by calling 1-800-444-5445.

Step 5: Once you receive your HUMANA letter, contact the listed Specialty Care Provider on the letter to book your appointment.
 
 Note:   1) If the listed Specialty Care Provider is NOT who you would like to see, please contact HUMANA at 1-800-444-5445)
 
            2) Following your initial Specialty Care Appointment, your Specialty care provider may want additional procedures, tests, surgeries and/or additional appointments. This can be accomplished by the Specialist contacting HUMANA for additional service approval. (Outpatient Request Form)
   
Step 6: Obtain a copy of your clinical notes: After your specialty care  appointment, please encourage your  provider to FAX a copy of your clinical notes to confidential. FAX # (410) 293-1149