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TRICARE Policy Manual 6010.63-M, April 2021
Chapter 1
Section 7.1
Primary Care Managers (PCMs)
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
1.0  Policy
1.1  TRICARE Prime enrollees shall select or have assigned to them PCMs according to guidelines established by the Market Director/Military Medical Treatment Facility (MTF) Director, or other Government Designated Authority (GDA).
1.1.1  A PCM may be a network provider, or a Market/MTF 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 a Market/MTF or network provider to provide the specialty care and in scheduling an appointment.
1.4  The contractor shall conduct a prospective review and authorize the service in accordance with the contractor’s best practices.
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 SUD visits.
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