1.0 Policy
1.1 TRICARE
Prime enrollees shall select or have assigned to them PCMs according
to guidelines established by the Military Treatment Facility (MTF)
Commander/Enhanced Multi-Service Market (eMSM) Manager and Director,
TRICARE Regional Offices (TROs).
1.1.1 A PCM may be a network provider,
or an MTF/eMSM PCM by name/supported by a team. If a group practice
is listed as a network provider, all members of the group practice
must be TRICARE-authorized providers.
1.1.2 The following
types of individual professional providers are considered primary
care providers and may be designated PCMs, consistent with governing
State rules and regulations: internists, family practitioners, pediatricians,
General Practitioners (GPs), obstetricians/gynecologists (OB/GYNs),
Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified
Nurse Midwives (CNMs).
1.2 A TRICARE Prime enrollee must
seek all his or her primary health care from the PCM with the exception
of Clinical Preventive Services. If the PCM is unable to provide
a primary care service, the PCM is responsible for referring the
enrollee to another primary care provider. A TRICARE Prime enrollee must
be referred by the PCM for specialty care or for inpatient care. For
mental health and Substance Use Disorder (SUD) care, all inpatient
and outpatient services, except office-based, outpatient treatment
provided by a network provider, require a referral. However, if
the non-office based, outpatient mental health or SUD provider is
a network provider, a request for preauthorization from the network
provider to the contractor may be accepted in lieu of PCM referral. Failure
to obtain a PCM referral when one is required will result in the
service being paid under Point of Service (POS) procedures
with a deductible for outpatient services and cost-shares for in-
and outpatient services.
1.3 The PCM is responsible for
notifying the contractor that a referral is being made. The contractor will
assist the Prime enrollee in locating an MTF/eMSM or network provider
to provide the specialty care and in scheduling an appointment.
Additionally, the contractor will conduct a prospective review and
authorize the service in accordance with the contractor’s best practices.
2.0 EXCEPTIONS
PCM referral is not required for the following
services:
2.1 Services provided directly by the PCM.
2.2 Emergency
care.
2.3 Services provided as part of the comprehensive
clinical prevention program offered to Prime enrollees.
2.4 Outpatient,
office-based, mental health and Substance Use Disorder (SUD) visits.