Referrals and Authorizations

<h2>REFERRALS AND AUTHORIZATIONS</h2> {notice:The Primary Care Manager (PCM) Referral Waiver in place due to the impacts of Hurricane Fiona for all TRICARE Prime Overseas and TRICARE Prime Remote Overseas enrolled beneficiaries seeking/receiving care in Puerto Rico and the Dominican Republic expired on October 31, 2022. For more information,} <a href="https://tricare-overseas.com/beneficiaries/enrollment-and-eligibility/recent-pcm-referral-waivers" target="_blank">click here</a>{notice:.} {fontweight=500:TRICARE Prime Overseas and TRICARE Prime Remote Overseas:} TRICARE Prime Overseas and TRICARE Prime Remote Overseas Active Duty Service Members (ADSMs) always require referrals for any civilian care, including clinical preventive services, mental health care, and specialty care (except for emergency services). TRICARE Prime Overseas and TRICARE Prime Remote Overseas Active Duty Family Members (ADFMs) do not need referrals for certain services. These include clinical preventive services and outpatient mental health care to a network host nation provider for a medically or psychologically diagnosed and covered condition.  {fontweight=500:Note:} Certain types of behavioral health care services, including non-emergency inpatient behavioral health care, are excluded and always require a referral or prior authorization. Contact International SOS for more details. A physician referral and supervision is always required to see pastoral counselors and may be required to see mental health counselors. {fontweight=500:TRICARE Select Overseas:} TRICARE Select Overseas is a self-managed, Preferred Provider Organization (PPO) style program that provides access to both network and non-network TRICARE authorized providers for medically necessary TRICARE covered services. TRICARE Select Overseas is an option for eligible non-ADSMs living overseas. TRICARE Select Overseas requires enrollment; however, retirees should expect to pay up front for health care and file claims for reimbursement. Under TRICARE Select Overseas, beneficiaries may receive care from any overseas civilian provider without a referral. However, certain services require prior authorization.  Providers may request payment directly from TRICARE Select Overseas beneficiaries or they may (but are not required to) submit claims on their behalf. TRICARE Select Overseas beneficiaries who pay up-front must then submit the (<a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf" target="_blank">Patient’s Request for Medical Payment (DD Form 2642</a>) to the TOP Claim Processor for reimbursement. {fontweight=500:Note:} Beneficiaries who live or travel in the Philippines are required to see a certified provider for care. TRICARE Select Overseas beneficiaries who reside in the Philippines and seek care within the designated Philippine locations are encouraged to see a TRICARE Preferred Provider. Philippine Demonstration Approved Providers were converted to {contentlink=/beneficiaries/philippines/philippine-provider-search:TRICARE Preferred Providers} as of January 1, 2018. <h4>Referrals for Specialty Care</h4> {fontweight=500:TRICARE Prime Overseas and TRICARE Prime Remote Overseas:} TRICARE Prime Overseas and TRICARE Prime Remote Overseas Active Duty Service Members (ADSMs) require prior authorization for all inpatient and outpatient specialty care services. An additional fitness-for-duty review is required for maternity care, physical therapy, mental health care services, and family counseling. Contact your TOP Regional Call Center for details about obtaining referrals. If you live near a military hospital or clinic and are referred for specialty care, inpatient admissions, or procedures requiring prior authorization, your TOP Regional Call Center attempts to coordinate care at your military hospital or clinic first. If services are not available at the military hospital or clinic, the TOP Regional Call Center coordinates care with a network purchased care sector provider. If your PCM refers you to a specialist who would like to refer you to another specialist, the specialist must contact your PCM. For TRICARE Prime Remote Overseas beneficiaries, the specialist must contact your TOP Regional Call Center to obtain prior authorization for additional specialty care, if necessary. For TRICARE Prime Overseas beneficiaries, your military hospital or clinic will issue a referral for care. <h4>Services Requiring Prior Authorization</h4> For all non-Active Duty Service Members (ASDMs) enrolled in a TRICARE Prime option, the following services require prior authorization: <ul> <li>Adjunctive dental services (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition)</li> <li>Nonemergency care received in the continental United States</li> <li>Extended Care Health Option services (ADFMs only)</li> <li>Home health care services*</li> <li>Home infusion therapy*</li> <li>Hospice care*</li> <li>Non-emergency inpatient admissions for substance use disorders and mental health care</li> <li>Other mental health services, such as partial hospitalization, child and adolescent psychiatric residential treatment center care, and outpatient psychoanalysis</li> <li>Transplants—all solid organ and stem cell†</li> </ul> This list is not all-inclusive, and each overseas area may have additional prior authorization requirements. Contact your TOP Regional Call Center to learn about requirements in your region, as they may change periodically. * These services are only covered in the United States and U.S. territories. † Medicare certification for organ transplant centers is only required for transplants performed in the United States and U.S. territories where Medicare is available. TRICARE may cover organ transplants in overseas locations when medically necessary, reasonable, and commonly accepted in the country where the transplant is performed. For more information about TRICARE Covered Services, Limitations, and Exclusions as well as information about when referrals or prior authorizations are required, please contact your TOP Regional Call Center or visit <a href="https://tricare.mil/CoveredServices" target="_blank">https://tricare.mil/CoveredServices</a>

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