Authorization/Referral Frequently Asked Questions

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1. What is a referral? What is an authorization?
   
   
2. I am a Prime beneficiary - how can I find out which procedures require prior authorizations?
   
   
3. I am a Prime beneficiary - what happens if I receive specialty care without a referral or authorization?
   
   
4. I am a Prime beneficiary – what do I need to do with the referral?
   
   
5. I am a Prime beneficiary – what services can I receive without a referral?
   
   
6. Can I check my referral and authorization information online?
   
   
7. Can an existing authorization be extended to include additional dates?
   

What is a referral? What is an authorization?

1. A provider referral is issued to TRICARE Prime beneficiaries in need of specialty care that their primary care manager (PCM) can not provide. TRICARE Standard beneficiaries do not need referrals.

Some services, for both Prime and Standard beneficiaries, require review and approval from a TriWest (or your regional TRICARE contractor) clinical staff member before the provider is permitted to render the service. If the service is approved, it is assigned an authorization number.

Authorizations may be needed for certain procedures. Typically, network or contracted TRICARE providers require authorizations to provide specialty or inpatient care. Contact TriWest or your regional contractor to determine if an authorization is needed.

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I am a Prime beneficiary - how can I find out which procedures require prior authorizations?

2. As a Prime family beneficiary, all procedures not performed by your primary care manager (PCM) (except emergency care, clinical preventive services and some behavioral health care) require prior authorization.

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I am a Prime beneficiary - what happens if I receive specialty care without a referral or authorization?

3. For non-emergency care, the TRICARE Prime point of service (POS) option applies if TRICARE Prime and TRICARE Prime Remote for Active Duty Family Member (TPRADFM) beneficiaries receive specialty care without authorization.

Active duty Service members must have a referral and authorization before seeking specialty care.

The POS deductible applies only to outpatient services, and the cost-share applies to both inpatient and outpatient services. TRICARE reimbursement under POS is limited to 50 percent of the TRICARE allowable charge.

The POS option also applies to prescription drugs. If you take your prescription into a non-network pharmacy, you will pay more. POS cost-sharing and deductible amounts do not apply if you have other health insurance (OHI). The POS deductibles and cost-shares are as follows (for all beneficiary categories):

Deductibles: $300 per individual/$600 per family
Cost-share: 50 percent of the TRICARE allowable charge

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I am a Prime beneficiary – what do I need to do with the referral?

4. Your primary care manager (PCM) will provide your routine health care. If you need to see a specialist for a diagnosis or treatment, your PCM will provide referrals and coordinate the referral requests through TriWest for you.

Important facts about specialty referrals:

• TRICARE Prime beneficiaries will be referred to an MTF first when the MTF can provide the specialty services needed. Call 1-888-TRIWEST (1-888-874-9378) for specific information about the MTFs in your TRICARE Prime service area
• Specialty care referrals will be approved for a specific length of time and number of visits.
• Follow the appropriate procedure for specialty referrals to avoid responsibility for charges other than any applicable copayments or cost-shares
• If you have other health insurance, you must follow the network referral rules for that carrier

After your PCM has issued a referral request, TriWest will assist with finding specialty care at either a military treatment facility (MTF) or, if the services are not available in the MTF, within the TRICARE provider network.

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I am a Prime beneficiary – what services can I receive without a referral?

5. Active duty Service members need a referral for the first behavioral health visit.
There is no requirement for a retired or active duty family member to have a PCM referral or authorization for the following services:

• Those services provided by the selected, assigned or "on-call" PCM
• Clinical preventive services
• Emergency Care
• Behavioral health services active duty Service members need a referral for the first

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Can I check my referral and authorization information online?

6. Yes, as a registered user of TriWest.com, you can check your authorization and referral information online and get your status information, along with the ability to print a copy of your authorization. If you are a TRICARE beneficiary, you can register here. Once you are registered and logged into your TriWest.com account, under the Check Status section on the Welcome page there is a link to “Check Authorization and Referral Status.” Follow that link for information on your current authorizations and referrals.

When you register, you will also receive a QuickAlert e-mail notification when there is an update to your referral or authorization status.

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Can an existing authorization be extended to include additional dates?

7. Yes. The provider who initially obtained the authorization or the provider performing the services may request an extension from TriWest of a valid authorization and the extension may be granted if all criteria, including medical necessity, are met.

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