You’re having heart problems. Your kid is having asthma difficulties. Maybe there’s a cancer scare, or maybe there’s a pregnancy. There are many possible reasons to see a specialist instead of your normal doctor.
Regardless of why you need to make the appointment, you have another concern that has little to do with the health issues involved. Specialist doctors can be expensive, and you want to make sure your costs are covered. If you’re a military retiree enrolled in TRICARE Prime, this is what you need to know about referrals.
How Can You Get a Referral?
If you’re enrolled in TRICARE Prime, you should have a primary care manager (PCM), the doctor who provides your regular care. If you think you need to see a specialist, talk to your PCM first. Your PCM will refer you to a specialist so you can get the care you need.
In addition to the referral, you may also need prior authorization. This means that the regional contractor must review and approve the care before the appointment occurs. Your PCM will arrange for this when providing the referral. Once the authorization is given, you will receive a letter telling you where you can get care.
When Do You Not Need a Referral?
Sometimes a referral is not necessary or practical.
For example, you don’t need a referral when seeking urgent care. However, in order to avoid paying higher out-of-pocket costs, you should go to a network provider or a TRICARE-authorized urgent care center.
Additionally, you don’t need a referral when seeking preventative services. These include various tests and screenings, such as blood pressure screening, cholesterol testing, immunizations, well-woman exams, and well-child care. Once again, it’s important to see a network provider to avoid additional costs. Look here for a list of TRICARE-covered preventative services.
What if You Need a Referral and Don’t Get One?
If you’re enrolled in TRICARE Prime and you don’t get a needed referral or if you go to a non-network provider, you may be charged fees based on the point-of-service option. This can be significantly more expensive.
Under the point-of-service option, you have an individual deductible of $300 and a family deductible of $600. You will also be charged 50 percent of the TRICARE allowable charge for both outpatient services and hospitalization. You will pay these point-of-service fees instead of the co-pay you normally pay.
On top of these fees, if you see a non-network provider, you may receive a bill for additional charges. Known as balance billing, this is what happens when a non-participating provider charges more than the TRICARE allowable charge. Although there are restrictions on balance billing for TRICARE enrollees, these additional costs can still come as an unpleasant surprise.
What if You’re Not Enrolled in TRICARE Prime?
So far, we’ve focused on how you should get specialist care if you are enrolled in TRICARE Prime. However, in addition to TRICARE Prime, there are other TRICARE plans, and they work differently.
If you are enrolled in TRICARE Select, you do not have a PCM. Because TRICARE Select is self-managed, you do not need a referral to see a specialist. But be careful – you may still need prior authorization.
Prior authorization is needed for certain services, which include extended care health option services, provisional coverage program services, hospice care, transplants, home health services, applied behavior analysis, and adjunctive dental services.
To get prior authorization, you must contact your regional contractor. Look here to learn more about prior authorization requirements.
As with TRICARE Prime, it’s important to see network providers in order to avoid additional out-of-pocket costs.