Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Policy Manual 6010.60-M, April 1, 2015
Administration
Chapter 1
Section 7.1
Primary Care Managers (PCMs)
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
Revision:  C-25, June 15, 2018
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.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.7.7887.17454

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.