Navigating TRICARE: Your Guide to Referrals and Authorizations

Last updated 3 months ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

Understanding how to get healthcare through TRICARE can sometimes feel complex, especially when dealing with referrals and authorizations. This guide breaks down what these terms mean, when you need them, and how the process works.

What Are TRICARE Referrals and Pre-Authorizations?

Within the TRICARE system, referrals and pre-authorizations act as checkpoints to ensure care is necessary, appropriate, and covered under your plan.

Referral: A recommendation from your primary care manager (PCM) to see a specialist for care that the PCM doesn’t offer. For certain plans, getting this referral is crucial for TRICARE to cover the specialist visit at the lowest cost.

Pre-authorization: A formal approval process where your TRICARE regional contractor reviews a specific requested medical service, procedure, or medication before you receive it. This confirms that the care is medically necessary, a covered TRICARE benefit, and safe and effective.

Failing to get a required referral or pre-authorization can lead to significantly higher out-of-pocket costs or even denial of coverage.

Which TRICARE Plans Require Referrals and Authorizations?

Whether you need a referral or pre-authorization largely depends on your specific TRICARE plan and sometimes your beneficiary status.

Referral Requirements

TRICARE Prime Plans: If you are enrolled in a TRICARE Prime plan, you need a referral from your PCM to see most specialists or receive certain diagnostic services. This includes:

• TRICARE Prime
• TRICARE Prime Overseas
• TRICARE Prime Remote
• TRICARE Prime Remote Overseas
• TRICARE Young Adult-Prime
• US Family Health Plan (USFHP) – referral comes from your designated USFHP provider

Active Duty Service Members (ADSMs) on Prime: You need a referral for any care your PCM doesn’t provide, including urgent care, routine care, preventive care, and specialty care received outside your assigned military hospital or clinic. Getting care without a referral means you may have to pay the full cost out-of-pocket.

Other Prime Beneficiaries (Non-ADSM): You typically need referrals for specialty care and some diagnostic services. However, you generally do not need a referral for preventive services or outpatient mental health care visits when seeing a TRICARE network provider in your region. Urgent care usually doesn’t require a referral (except for ADSMs). If you see a specialist without a required referral, you’ll be using the “point-of-service” (POS) option, which involves higher costs (deductibles and cost-shares).

TRICARE Select and Premium-Based Plans: These plans offer more flexibility. You generally do not need a referral for most primary and specialty care visits. This includes:

• TRICARE Select
• TRICARE Select Overseas
• TRICARE Reserve Select (TRS)
• TRICARE Retired Reserve (TRR)
• TRICARE Young Adult-Select
• TRICARE For Life (TFL)

Exception – Applied Behavior Analysis (ABA): Regardless of your plan (including Select and TFL), ABA services for autism spectrum disorder require both a referral and ongoing authorizations.

Pre-Authorization Requirements

While general referrals are mostly tied to Prime plans, the need for pre-authorization for specific services is more widespread across TRICARE.

TRICARE Prime Plans:

• ADSMs need pre-authorization for all inpatient and outpatient specialty services. Some care also requires a fitness-for-duty review.
• Other Prime beneficiaries need pre-authorization for specialty care (obtained along with the referral) and certain other services like inpatient admissions and some behavioral health services.

TRICARE Select, Premium-Based Plans, and TFL: Even though referrals aren’t usually needed, pre-authorization is required for certain types of care and services. Common examples include:

• Adjunctive dental services (dental care needed to treat a covered medical condition)
• Applied Behavior Analysis (ABA)
• Home health services
• Hospice care
• Inpatient admissions (hospital stays), including some behavioral health admissions
• Transplants (all solid organ and stem cell)
• Services under the Extended Care Health Option (ECHO)
• Certain services under the Provisional Coverage Program
• Some specific pain treatments or other procedures
• Certain prescription drugs

This list is not exhaustive. Verify pre-authorization requirements for specific services before receiving care. You can check the TRICARE referrals page or the covered services section on the TRICARE website, or contact your regional contractor.

Here’s a summary table:

Note: Always verify requirements for your specific situation.

The TRICARE Referral Process

If you are enrolled in a TRICARE Prime plan and need specialty care, understanding the referral process is key to accessing that care smoothly and affordably.

Who Starts the Referral?

Your assigned Primary Care Manager (PCM) initiates the referral process. This could be a provider at a military hospital or clinic (MTF) or a civilian network provider designated as your PCM. For TRICARE Prime Remote beneficiaries without an assigned PCM, you work directly with your regional contractor. USFHP members get referrals from their designated USFHP provider.

The Steps Involved

1. PCM Assessment: During your appointment, your PCM determines you need care they cannot provide (e.g., specialty consultation, specific diagnostic test).
2. Referral Request Submission: Your PCM submits a referral request electronically to your TRICARE regional contractor (Humana Military for the East Region, TriWest Healthcare Alliance for the West Region, or International SOS for overseas). ADSMs’ PCMs work with the regional contractor; remote ADSMs’ civilian PCMs also send referrals to the contractor.
3. Contractor Review & Processing: The regional contractor reviews the request. This typically involves checking for medical necessity and ensuring the service is a covered benefit. They may also check if a military hospital or clinic can provide the care first (see “Right of First Refusal” below).
4. Authorization Issued: Once approved, the contractor issues an authorization letter. This letter contains details about the approved specialist/provider, the specific care authorized (including the number of visits), and the referral’s expiration date. You can usually access this letter electronically via your contractor’s secure online portal.

Typical Timelines

Processing Time: It generally takes about three business days for the regional contractor to process a standard referral request. If your PCM marks the referral as “clinically urgent,” processing may be faster.

Appointment Access Standard: Once authorized, you should generally be able to get an appointment with the specialist within 28 days or four weeks. If you cannot get an appointment within this timeframe, contact your regional contractor.

Referral Validity

Duration: Most referrals are valid for 180 or 365 days, but this can vary. Always check the expiration date on your authorization letter.

Expiration: You must get the care before the authorization expires. If it expires, you’ll need to go back to your PCM and request a new referral and authorization. For ongoing care needs, request a new referral at least 30 days before the current one expires to avoid gaps in care.

What the Beneficiary Does

1. Check Status: Monitor the status of your referral via your regional contractor’s online portal or by phone.
2. Receive Authorization: Once approved, access and review your authorization letter online.
3. Schedule Appointment: Contact the specific provider listed on the authorization letter to schedule your first appointment. Do this promptly to ensure you get care before the expiration date.
4. Need a Different Provider? If you want to see a different specialist than the one listed, or if the listed provider is too far away (e.g., >60 minutes), contact your regional contractor before making an appointment.
5. Attend Appointment: Bring your military ID and a copy of your referral authorization letter to your appointment. Ask the specialist’s office beforehand if they need any other records (like X-rays or lab results) from your PCM.

Right of First Refusal

In some areas, particularly near MTFs, the regional contractor may first send the referral to the local military hospital or clinic. The MTF has the “right of first refusal” – they can accept the referral if they have the capability and capacity, or refuse it. If the MTF refuses, the contractor will then authorize care with a civilian network provider. You will be notified if your care is directed to an MTF.

Getting a Second Opinion

You have the right to request a second medical opinion. Discuss your concerns with your PCM, who can initiate a referral to another specialist if appropriate.

The TRICARE Pre-Authorization Process

Pre-authorization (or prior authorization) is a critical step for certain medical services, procedures, and prescription drugs across most TRICARE plans. It confirms coverage before you receive the service, protecting you from unexpected costs.

When is Pre-Authorization Needed?

Specific Medical/Surgical Services: Services like inpatient stays, home health, hospice, ABA, transplants, adjunctive dental care, ECHO services, and certain behavioral health treatments typically require pre-authorization, even for plans like TRICARE Select or TFL. ADSMs need pre-authorization for virtually all specialty care.

Prescription Drugs: Pre-authorization is often required for certain medications to ensure they are safe, effective, medically necessary, and cost-effective. This may apply if the drug:

• Is specified by the DoD Pharmacy & Therapeutics Committee
• Is a brand-name drug with a generic equivalent available
• Has specific age limits
• Is prescribed in a quantity exceeding normal limits
• Is a non-formulary drug (may require “medical necessity” justification instead of/in addition to pre-auth)

How to Check if Pre-Authorization is Needed

• Medical Services: Consult the referrals page, the covered services section of tricare.mil, or ask your provider or regional contractor. The West Region may offer a specific decision support tool via the TriWest portal.
• Prescription Drugs: Use the TRICARE Formulary Search Tool available via the TRICARE pharmacy page. Search for your drug; if pre-authorization or medical necessity is required, the tool will indicate this and provide links to the necessary forms.

The Process for Getting Pre-Authorization

Medical/Surgical Services:

1. Your provider identifies the need for a service requiring pre-authorization.
2. The provider’s office submits a pre-authorization request, along with supporting medical documentation, to your TRICARE regional contractor. This step is primarily the responsibility of the provider’s office, highlighting the importance of choosing providers familiar with TRICARE processes.
3. The regional contractor reviews the request based on TRICARE policy, coverage rules, and medical necessity criteria.
4. The contractor issues a decision (approval or denial) and notifies both the provider and the beneficiary. Approved requests include an authorization number and specify the approved service and validity period.
5. You must wait for this approval before receiving the service.

Prescription Drugs:

1. Check the TRICARE Formulary Search Tool to confirm if pre-authorization or medical necessity is needed and download the specific form.
2. Give the form to your prescribing provider.
3. Your provider must complete the form and submit it to Express Scripts (the TRICARE pharmacy contractor) following the instructions on the form. This reliance on the provider underscores the need for clear communication between patient and prescriber.
4. Express Scripts reviews the request and notifies you and your provider of the decision. You can check the status via your Express Scripts online account or mobile app.
5. Approved authorizations apply at military pharmacies, network pharmacies, and through home delivery. Medical necessity approvals allow you to get non-formulary drugs at the lower formulary cost-share at network pharmacies and home delivery.

Timelines and Validity

Processing times for medical pre-authorizations can vary depending on the complexity and urgency. Pharmacy pre-authorizations are typically handled by Express Scripts; status can be tracked online. Some authorizations may take up to five days to appear in online accounts.

Authorizations are valid for a specific period. You must receive the service or fill the prescription within this timeframe. Check your authorization letter or approval details for the expiration date. If it expires, you need to restart the process.

Consequences of Not Getting Pre-Authorization

Receiving services or filling prescriptions that require pre-authorization without obtaining approval first can result in TRICARE denying coverage, leaving you responsible for the full cost. This highlights the importance of verifying requirements beforehand.

While referrals are primarily a concern for Prime plan users accessing specialists, the need for pre-authorization for certain high-cost or specialized services cuts across nearly all TRICARE plans, acting as a fundamental cost-control and utilization management tool within the system.

Finding Care and Checking Your Status

Successfully navigating TRICARE involves knowing how to find providers who accept your plan and how to check the status of your referrals and authorizations. Utilizing the official online tools is often the most efficient way to manage your care.

Finding TRICARE-Authorized Providers

Why It Matters: TRICARE will only cover services from “TRICARE-authorized” providers. Within this group, there are network and non-network providers.

Network Providers: These providers have signed agreements with your regional contractor. Using them usually means lower out-of-pocket costs (you typically only pay your copay/cost-share upfront), and they file claims directly with TRICARE for you. This is often the most convenient and affordable option.

Non-Network Providers: These providers are TRICARE-authorized but don’t have a network agreement.

• Participating Non-Network: They agree to accept the TRICARE-allowable charge as full payment and usually file claims for you. You pay your standard cost-share. They may participate on a case-by-case basis.
• Non-Participating Non-Network: They do not have to accept the TRICARE rate and can charge up to 15% above the TRICARE-allowable amount (this extra amount is called “balance billing,” and you are responsible for paying it). They may require you to pay the full bill upfront, and you will likely need to file your own claim with TRICARE for reimbursement. This is generally the most expensive option.

Using Official Provider Directories

Always use the official TRICARE tools to locate authorized providers:

• Main “Find a Doctor” Portal: Start at TRICARE Find a Doctor. This page helps direct you to the correct directory based on your plan and location. You can also use the comprehensive All Provider Directories page.
• East Region Directory (Humana Military): Access via TRICARE East or the Humana Military site.
• West Region Directory (TriWest Healthcare Alliance): Access via TRICARE West or the TriWest beneficiary portal.
• Overseas Provider Directory (International SOS): Find providers via TRICARE Overseas. Note special certification requirements for providers in the Philippines.
• Military Hospitals/Clinics (MTFs): Use the MTF locator tool.
• US Family Health Plan (USFHP): Each USFHP designated provider has its own network directory. Links are available on the main TRICARE site or directly from providers like Johns Hopkins, Martin’s Point, etc.
• TRICARE For Life (TFL): Since Medicare is the primary payer in the U.S., use the official Medicare Care Compare tool. Look for providers who accept Medicare assignment.

Confirming if You Need a Referral or Authorization

Don’t assume – always double-check requirements before seeking non-primary care.

• Review your plan details on TRICARE.mil.
• Check the central referrals page.
• Consult the covered services section for specific procedures.
• Ask your PCM (especially if you’re on a Prime plan).
• Contact your regional contractor directly.
• West Region beneficiaries may have access to a specific Referral and Authorization Decision Support tool via the TriWest portal.

Checking the Status of Your Referral or Authorization

Online Beneficiary Portals (Recommended): This is the fastest way to get updates. You must register for an account, typically using a DS Logon, DFAS (MyPay) account, or CAC. These portals are essential for managing your care effectively, offering near real-time status and access to important documents like authorization letters.

• East Region Portal (Humana Military): Access via TRICARE East or Humana Military. Check status, view letters, manage payments, check claims.
• West Region Portal (TriWest): Access via TRICARE West or TriWest beneficiary portal. View details, check status, find providers, manage care.
• Overseas Portal (MyCare Overseas / International SOS): Access via TRICARE Overseas using the app or web portal. Check status, file claims, view Explanation of Benefits (EOBs).

Important Distinction – MHS GENESIS: The MHS GENESIS Patient Portal is primarily for your health records, booking/managing appointments at MTFs, secure messaging with your MTF care team, and viewing lab/test results. It does not typically display the status of referrals or authorizations managed by your regional contractor. You need to use the separate regional contractor portals for that administrative information. This separation means beneficiaries often need to use multiple online systems (DEERS/milConnect for eligibility, MHS GENESIS for MTF records/appointments, Regional Portal for referrals/authorizations/claims, Express Scripts for pharmacy) depending on their task.

TRICARE Online (TOL): This portal has been retired as of April 1, 2025, and replaced by MHS GENESIS. Any older guidance pointing to TOL for referral status is outdated.

Checking by Phone: You can always call your regional contractor’s customer service line:

• East Region (Humana Military): 1-800-444-5445
• West Region (TriWest Healthcare Alliance): 1-888-TRIWEST (874-9378)
• Overseas (International SOS): Find country-specific numbers at TRICARE Overseas Contact Us

Handling Challenges: Appeals, Grievances, and Getting Support

Even with careful planning, you might encounter challenges with the referral and authorization system. Knowing how to address denials, delays, or other issues is crucial. TRICARE provides formal processes for resolving disputes and various support resources.

Common Challenges

Beneficiaries sometimes experience denials of referrals or pre-authorizations, delays in getting approvals, difficulty finding network specialists who are accepting new patients or can offer timely appointments, and general confusion about the rules. Transitions between regional contractors, like the recent change in the West Region, can also temporarily create hurdles.

Appealing Denied Authorizations or Claims

If TRICARE denies a pre-authorization request or denies payment for a service you received, you have the right to formally appeal the decision. There are distinct processes based on the reason for denial. Success in these processes often hinges on providing clear, written arguments and supporting documents within strict deadlines, highlighting the need for good record-keeping.

Medical Necessity Appeals: File this type if pre-authorization was denied because TRICARE determined the service wasn’t medically necessary.

• Timeline: Must be filed within 90 days of the date on the denial letter/EOB. Expedited appeals (for urgent situations like continuing inpatient stays) have a shorter deadline, often 3 days.
• Process: Submit a written appeal to the designated appeals address for your region (check denial letter or TRICARE website). Include a copy of the denial, your reasons for appealing, and any supporting medical documentation. If the initial appeal is denied, further levels of review (e.g., TRICARE Quality Monitoring Contractor, DHA formal review, independent hearing for larger disputed amounts) may be available, each with its own deadlines and procedures.

Factual Appeals: File this type if a claim was denied for reasons other than medical necessity (e.g., questions about eligibility, coding errors, timely filing, non-covered benefit).

• Timeline: Must be filed within 90 days of the date on the EOB or other decision notice.
• Process: Submit a written appeal to your contractor’s appeals address, including the EOB/decision copy and supporting documents. If the contractor denies the appeal, further review by DHA may be possible if the disputed amount meets certain thresholds ($50 or more for DHA review, $300 or more for a potential independent hearing), following specific procedures and deadlines (e.g., 60 days for next level).

Where to Submit Appeals: Use the specific address, fax number, or online portal indicated in your denial letter or found on the TRICARE website’s appeals section or your regional contractor’s site. Addresses vary by region (East, West, Overseas, TFL) and type of appeal.

Filing a Grievance

If your concern isn’t about a denied benefit or claim, but about the quality of care received (at an MTF or civilian provider), unprofessional behavior by staff, problems with access (like excessive wait times for appointments), or facility issues, the appropriate channel is a grievance.

Process: Submit a written complaint detailing the issue. Include beneficiary information (name, DOB, sponsor SSN), date, time, location, names of involved parties, a clear description of the concern, and any supporting documents.

Where to Submit: Send to the designated Grievance Coordinator or department for your TRICARE regional contractor, pharmacy contractor (Express Scripts), or the specific MTF involved. Addresses and contact information are available on the TRICARE website and contractor sites.

Resolution: Contractors and MTFs have processes to investigate grievances and typically provide a written response, often within 60 days.

Getting Help and Support

Navigating these processes can be challenging. TRICARE offers several resources:

• Regional Contractors: Your first stop for questions about your plan, benefits, claims, referrals, and finding network providers. Contact information is in previous sections.
• Beneficiary Counseling and Assistance Coordinators (BCACs): Located at MTFs, BCACs are TRICARE benefit experts. They can help after you’ve contacted your regional contractor, assisting with complex enrollment, eligibility, referral, authorization, or claims issues. They can explain DEERS information and liaise with contractors. You can walk in or call; find them via the MTF directory or customer service lists. This layered support system, starting with the contractor and escalating to the BCAC if needed, ensures multiple avenues for help.
• Patient Advocates: Also at MTFs, they focus specifically on issues related to care received at the MTF, patient rights, and mediating concerns between patients and the MTF clinical team. Contact them for MTF-specific quality of care or experience issues.
• Debt Collection Assistance Officers (DCAOs): At MTFs, they assist with resolving confirmed debt collection issues related to TRICARE claims, but only after you’ve attempted to resolve it with the contractor.
• MHS Nurse Advice Line: Provides 24/7 clinical advice from registered nurses. Call 1-800-TRICARE (874-2273), Option 1. (Remember ADSMs may still need a referral for urgent care even after calling).
• TRICARE Website: The primary source for official information, forms, policies, and contact directories.

Key Official TRICARE Resources

Having direct access to official information is vital for managing your TRICARE benefits. Here are some essential websites and contact points:

• Main TRICARE Website: Your starting point for all TRICARE information, including plan details, covered services, costs, and news. https://tricare.mil/
• Referrals and Pre-Authorizations Page: Specific details on when these are needed and how the processes work. https://tricare.mil/referrals
• Find a Doctor / Provider Directories: Tools to locate TRICARE-authorized network providers, MTFs, and specialists.
  • Main Portal: https://tricare.mil/finddoctor
  • All Directories Page: https://tricare.mil/GettingCare/FindDoctor/AllProviderDirectories
• Find a Military Hospital or Clinic (MTF): Locator tool for MTFs worldwide. https://tricare.mil/mtf
• Regional Contractor Websites & Beneficiary Portals: Access regional provider directories, check referral/authorization status, manage claims, and update information.
  • East Region (Humana Military):
    • TRICARE Page: https://tricare.mil/east
    • Contractor Site: https://www.humanamilitary.com/
  • West Region (TriWest Healthcare Alliance):
    • TRICARE Page: https://tricare.mil/west
    • Beneficiary Portal Login: https://tricare-bene.triwest.com/
  • Overseas (International SOS):
    • Contractor Site/Portal Access: https://www.tricare-overseas.com/
• MHS GENESIS Patient Portal: Access your electronic health record, view MTF lab/test results, book MTF appointments, and message your MTF care team. https://patientportal.mhsgenesis.health.mil/
• milConnect: Check and update DEERS information (crucial for eligibility), manage TRICARE enrollment, and access other personnel/benefit information. https://milconnect.dmdc.osd.mil/milconnect/
• TRICARE Pharmacy Program (Express Scripts): Search the formulary, find pre-authorization forms, manage prescriptions, and set up home delivery.
  • Access via: https://www.tricare.mil/pharmacy
  • Direct Link (often): https://militaryrx.express-scripts.com/
• Beneficiary Support Contacts (BCACs, Patient Advocates, DCAOs): Find contact information for support staff at MTFs.
  • Use the MTF Locator: https://tricare.mil/mtf
  • MHS Customer Service Community Directory: https://tricare.mil/PatientResources/MHS-Customer-Service-Directory
• MHS Nurse Advice Line: 24/7 medical advice from registered nurses.
  • Phone: 1-800-TRICARE (874-2273), Option 1

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