Military Health System

2.1  Self referred non-emergency specialty or inpatient care provided to a TRICARE Prime enrollee either within or outside the network, which is neither provided by the patient’s PCM or referred by the PCM, nor authorized by the contractor, shall be reimbursed under the POS option if it is a benefit under TRICARE Basic Program. See the TRICARE Operations Manual (TOM), Chapter 18 for exceptions.

2.2  The contractor shall apply Prime copayments, not POS cost-sharing provisions when PCMs, network providers and/or the contractor do not follow established referral/authorization procedures. For example, if the contractor processes a claim without evidence of an authorization and/or a referral under POS provisions, and the contractor later verifies that the PCM or other appropriate provider referred the beneficiary for the care, the contractor shall adjust the claim under Prime provisions. The contractor need not identify past claims, however the contractor shall adjust these claims as they are brought to their attention.

2.3  POS deductible and cost-share amounts follow for TRICARE Prime enrollees:

2.4  POS deductible and cost-share amounts are NOT creditable to the catastrophic cap and they are not limited by the cap.

2.5  POS deductible and cost-sharing do not apply to the claims for care received by certain newborn and newly adopted children not registered in Defense Enrollment Eligibility System (DEERS) or not enrolled in a TRICARE Plan for up to 90 days or up to 120 days if overseas after birth or adoption (see the TRICARE Policy Manual (TPM), Chapter 10, Section 3.1).

2.6  All TRICARE coverage provisions apply to POS claims with the exceptions noted in this section.

3.1  The TRICARE Prime clinical preventive services do not require preauthorization or authorization. Most of the services covered as clinical preventive services are provided directly or ordered by the patient’s PCM. In those cases that patients can self-refer for services (i.e., eye examinations), patients must use network providers. If the patient does not use a network provider, payment shall be made under the POS option ONLY for preventive services that are otherwise covered under the TRICARE Basic Program (e.g., 32 CFR 199.4(e)(28)).

3.2  POS cost-sharing and deductible amounts do not apply if an enrollee has Other Health Insurance (OHI) that provides primary coverage, i.e., the OHI must be primary under the provisions of Chapter 4, Section 1; and documentation that the OHI processed the claim and of the exact amount paid must be submitted with the TRICARE claim. TRICARE Prime provisions apply for this type of claim.

3.3  POS cost-sharing does not apply to TRICARE Prime enrollees who obtain outpatient mental health care from a network provider without a referral from their PCM.