If you are enrolled in TRICARE Prime, all of your care should be coordinated through your primary care manager (PCM). The PCM’s office determines whether or not they will require you to make an appointment prior to receiving a specialist’s referral. That determination is based on the relationship you have with your primary care manager (PCM) and the knowledge that PCM has regarding your medical history and condition.
TRICARE Prime offers you a higher level of coverage, at a lower out-of-pocket cost, when your medical care is provided or coordinated by your primary care manager (PCM) and approved by the health care finder (HCF). One way that the PCM coordinates your care is through the use of referrals. Whenever you need to see a specialist or go to a hospital for non-emergency medical care, your care must be coordinated by your PCM and approved by the health care finder (HCF) at your local TSC. If you receive non-emergency medical or hospital care without a referral from your PCM, you will be covered under the Point of Service (POS) option. The only exceptions are for clinical preventive services and the first eight mental health sessions per year. Beneficiaries are notified of routine specialty care referrals within ten days of the request.
Prime members utilize the Point of Service Option when they obtain non-emergency care without a referral from their Primary Care Manager. Under POS, beneficiaries are subject to a substantial deductible ($300 for an individual or $600 for a family) then a cost share of 50% of the TRICARE Maximum Allowable Charge (TMAC). Prime members may also be subject to additional charges (up to 15% over TMAC) if they see a non-network provider under the Point of Service option.
To avoid the high POS charges, always consult your PCM before seeing another doctor or going to the hospital for non-emergency care.
Some outpatient procedures and all non-emergency admissions to hospitals and skilled nursing facilities must receive an authorization for medical necessity from HMHS before they are performed. For Prime patients, their primary care manager (PCM) or network provider is responsible for initiating the authorization request. For patients seeing non-network providers, the patient or the doctor may make the prior authorization request.
For emergencies while traveling away from your home, you should go directly to the nearest hospital emergency department. We recommend that you or someone acting on your behalf notify your PCM as soon as possible after receiving emergency care for continuity of care purposes.
For treatment of a non-emergency medical condition that cannot wait until you return home, you should always coordinate with your PCM before seeking care.
If your need for care could have been handled before you left or delayed until you get home, it is considered routine care. TRICARE Prime does not cover costs for routine care while you are away from home. Beneficiaries who seek routine care while away from home will have their claims paid at the higher cost POS benefit level.
