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 Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 5
Referral Management (RM)
Revision:  
1.0  RM PROGRAM
1.1  The contractor shall establish and maintain a RM program as outlined in this Chapter.
1.2  The contractor shall review the referral request in accordance with Chapter 1, Section 3, to determine:
•  That the provider to whom the patient is referred meets applicable authorized provider and network provider requirements;
•  That the services being requested are a TRICARE covered benefit and are requested in a covered setting; and
•  Whether any specific services requested as part of the referral also require preauthorization.
1.2.1  The contractor shall provide a response to referrals and authorizations, as part of the process to completion (PTC).
1.2.2  The contractor shall send the response and updates to the referring provider, beneficiary and referred to provider and when applicable to the Markets/Military Medical Treatment Facilities (MTFs).
1.3  The contractor shall develop and provide a Health Insurance Portability and Accountability Act (HIPAA)-compliant web-based RM system that the Markets/MTFs can use to view referral details (to include but not limited to eligibility check information) and track Market/MTF referred care to and from private sector care and allows the Market/MTF to ascertain whether each referral resulted in beneficiary care. The system should be refreshed at a minimum of every 24 hours.
1.3.1  The contractor’s system shall, at a minimum, provide the status of all referrals, including ‘drill down’ detailed data at the individual referral level, and search functions using multiple parameters including but not limited to beneficiary, date range, provider, Market/MTF, specialty and Referral Case Number/Unique Identifier Number (UIN).
1.3.2  The contractor shall link claims data to the appropriate referral within its web-based system.
1.3.3  The contractor’s system shall allow for multiple file types to be uploaded from the Market/MTF to themselves, which includes, but is not limited to, Portable Document Format (PDF), Word, and imaging files.
1.3.4  The contractor’s RM system/portal shall include all authorization and denial correspondence to beneficiary and providers and be viewable by the Government.
1.4  The contractor shall collaborate with the Government to develop a table of acceptable secondary referrals that will allow identified specialty-to-specialty referrals within the same Episode of Care (EOC) for TRICARE Prime beneficiaries. The contractor may recommend or the Government may direct adding or deleting specialties from this table semiannually.
1.5  The contractor shall coordinate with other TRICARE Private Sector Care Contractors (PSCCs) (continental United States (CONUS) only) to ensure that all determinations about whether a referral, treatment, or service is a TRICARE covered benefit, is in a covered setting, and whether services that require preauthorization and specialty-to-specialty referrals are consistent, regardless of the beneficiary’s geographic location (within CONUS) and which PSCC the beneficiary is enrolled to.
1.6  The contractor shall utilize the Market/MTF Capability and Capacity tables to identify referrals and authorizations for TRICARE Prime beneficiaries to receive care at the MTF to meet Market/MTF Knowledge, Skills and Abilities (KSAs) to maintain readiness.
1.7  The contractor shall identify authorizations for TRICARE Select beneficiaries and offer TRICARE Select beneficiaries the choice to receive care at the MTF to meet Market/MTF KSAs to maintain readiness.
1.8  The contractor shall utilize automation in processing referral and authorization, EOCs, procedure and diagnosis coding.
1.9  The contractor shall conduct all referral communications with the Market/MTF using Department of Defense (DoD) system(s) approved electronic HIPAA secure transactions as outlined in TRICARE Systems Manual (TSM), Chapter 1, Section 1.1.
1.10  The contractor shall provide reports on all unactivated network referrals by specialty for all TRICARE Prime members enrolled to the government for all beneficiary categories. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
Note:  The UIN is specific to the Composite Health Care System (CHCS)/Armed Forces Health Longitudinal Technology Application (AHLTA) which is the legacy Military Health System (MHS) Electronic Health Record (EHR) and the legacy Referral Management Suite (RMS). As the MHS phases out legacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as the new EHR, the UIN will no longer be used. MHS Genesis produces the “Referral ID” thus the UIN and Referral ID may be used interchangeably in this Section.
2.0  URGENT CARE REFERRALS
2.1  Active Duty Service Members (ADSMs) enrolled in TRICARE Prime require a referral which they will obtain from the MTF provider or through the Nurse Advice Line (NAL). ADSMs enrolled to the TRICARE Overseas Program (TOP) or in TRICARE Prime Remote (TPR) will not be held to any urgent care referral requirement, but they are still held to applicable DoD and Service requirements concerning authorization for private sector care. Point of Service (POS) does not apply to ADSM private sector care.
2.2  Active Duty Family Members (ADFMs) enrolled in TRICARE Prime may self-refer for urgent care from a TRICARE network provider or a TRICARE-authorized (network or non-network) Urgent Care Center (UCC) or Convenience Clinic (CC). If the enrollee seeks care from a non-network provider (except a TRICARE-authorized UCC or CC), the usual POS deductible and cost-shares shall apply.
2.3  ADFMs enrolled in TRICARE Prime Remote Active Duty Family Member (TPRADFM) with an assigned Primary Care Manager (PCM) are required to seek urgent care from a TRICARE network provider or a TRICARE-authorized (network or non-network) UCC or CC to avoid POS.
2.3.1  ADFM in TPRADFM without an assigned PCM may utilize any local TRICARE participating or authorized provider for primary care services (to include urgent care services).
2.3.2   ADFMs and ADSMs enrolled to TOP Prime or TOP Prime Remote enrollees need to contact the TOP contractor to obtain an authorization in order to ensure their urgent care visit will be cashless and claimless. Without this authorization, overseas providers may request payment upfront and the enrollee will then have to submit a claim for reimbursement.
2.3.2.1  ADSMs enrolled to TOP Prime or TOP Prime Remote requiring urgent care while Temporary Duty (TDY) or on leave, in the 50 United States (US) and the District of Columbia, will not be held to any urgent care referral requirements, but they are still held to applicable DoD and Service regulations concerning ADSM care outside Markets/MTFs. The usual ADSM POS exception applies.
2.3.2.2  ADFMs enrolled to TOP Prime or TOP Prime Remote traveling in the 50 US and the District of Columbia, may access urgent care without a referral or an authorization, but POS deductibles and cost shares shall apply for claims when urgent care is not provided by a TRICARE network provider or a TRICARE-authorized (network or non-network) UCC.
2.4  If urgent treatment is required by a TRICARE Prime enrollee after hours, while traveling away from their residence, or whose PCM is otherwise unavailable, the enrollee may contact the NAL, their PSCC, TOP contractor, Designated Provider (DP) for assistance finding an appropriate facility and provider before receiving non-emergent care from a provider other than the PCM. If an enrollee is traveling overseas, he or she may call the TOP Regional Call Center for the region in which he or she is traveling to coordinate urgent care.
2.5  The contractor shall provide beneficiary and network provider education on obtaining an after hour appointment or UCC care to include information on how to contact the NAL, how to schedule follow-up appointments, and how to coordinate care.
2.6  When contacted by the beneficiary, the contractor shall encourage TRICARE Prime enrollees to notify their PCM of any urgent and acute care visits to providers, other than the PCM within 24 hours of the visit, or the first business day following the visit and to schedule follow-up treatment, if indicated, with their PCM, or to get a referral from the PCM for additional specialty care.
2.7  Urgent care can be rendered by a TRICARE network provider or TRICARE-authorized UCC. Providers must have one of the following primary specialty designations:
•  Family Practice
•  Internal Medicine; General Practice
•  Pediatrician
•  UCC or CCs
Note:  In accordance with TPM, Chapter 1, Section 7.1, Obstetricians/Gynecologists (OB/GYNs), Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs) can be considered Primary Care Providers (PCPs) and may also be designated PCMs.
3.0  Mental Health (MH) and Substance Use Disorder (SUD) Referrals
3.1  The contractor shall require a PCM referral for non-office based, outpatient (e.g., Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP) and Opioid Treatment Program (OTP)) MH services. However, if the non-office based, outpatient MH provider is a network provider, a request for preauthorization from the network provider to the contractor may be accepted in lieu of the PCM referral.
3.2  The contractor shall comply with the provisions of Chapters 16 and 17 when processing requests for active duty personnel. See Chapter 16, Sections 2 and 6 for referral requirements under the TPR program. ADSMs require referral and preauthorization before receiving all MH and SUD services.
3.3  The contractor shall process outpatient MH and SUD referrals to the subspecialty level in accordance with Chapter 1, Section 3 when submitted by a Market/MTF.
3.4  The contractor shall indicate in their portal whether the processed referral was approved or denied.
4.0  REFERRAL AND AUTHORIZATION PROCESSING
4.1  The contractor shall process referrals in accordance with Utilization Management (UM), Section 4, and the following:The contractor shall select the provider priority for referral in the following sequence:
4.2.1  Market/MTF via Capability And Capacity (aka KSA) tables and processes as outlined in the Memorandum of Understanding (MOU) between the Government and the contractor.
4.2.2  Network provider within Access To Care (ATC) standards.
4.2.3  Non-network provider within ATC standards.
4.2.4  Closest network provider outside of ATC standards, but within 100 miles.
4.2.5  Closest non-network provider outside of ATC standards, but within 100 miles.
4.2.6  Closest network provider outside 100 miles.
4.2.7  Closest non-network provider outside 100 miles.
4.2.8   When continuity of care is a consideration. See https://manuals.health.mil/pages/v3/DownloadManualFile.aspx?Filename=Definitions.pdf for the definition of continuity of care.
4.2.9  Out of Region when the care requested is of such a special nature that it cannot be rendered within the region and medical necessity warrants the care. This is expected to occur rarely.
4.3  Centralized Appointing Centers (Integrated Referral Management Appointing Centers (IRMACs)/Referral Appointing Centers (RACs))
4.3.1  The contractor shall collaborate with the Government to coordinate urgent and routine Direct Care System (DCS) referrals through the IRMACs/RACs (where available) to make prompt referrals to network providers under the TRICARE program.
4.3.2  The contractor shall provide up to 1,500 IRMAC/RAC personnel with read only access to its RM system. The contractor shall send the DCS enrolled beneficiary a message through the beneficiary’s primary means of communication (telephone, email, text, app) as soon as a referral has been approved and instruct them to contact the IRMAC/RAC to schedule an appointment.
4.4  Referrals from the Market/MTF to the Contractor
4.4.1   The contractor shall translate the narrative descriptions for a referral into standard diagnosis and procedure codes.
4.4.2  The contractor shall authorize care in their network and retain responsibility for managing requests for additional services or inpatient concurrent stay reviews associated with the original referral, as well as changes to the specialty provider identified to deliver the care.
4.4.2.1  The contractor shall apply the Market/MTF capability and capacity tables described in paragraph 4.6.1 and the secondary referral table described in paragraph 1.4 when determining and authorizing care for additional services that are requested beyond the initial referral within the same EOC.
4.4.2.2  The contractor authorizing the care shall forward the referral and authorization information, including the range of codes authorized (i.e., EOC), the name, the National Provider Identifier (NPI), and demographic information of the specialty provider to the contractor for the region to which the patient is enrolled, as well as the Market/MTF where enrolled, if applicable.
4.4.2.3  The contractor shall provide the same service and information required above to the TOP contractor, if the patient is enrolled overseas.
4.4.2.4  The contractor shall forward the authorization information to the TOP contractor to ensure appropriate adjudication of the claim, if a CONUS Prime retiree or retiree family member receives authorization to obtain care overseas from a contractor.
4.4.2.5  The contractor shall provide a report of all referrals and authorizations transferred from one contractor to another. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.4.3  The contractor shall provide a text explanation of why a referral was returned and rejected in a HIPAA-compliant 278 transaction within 24 hours to the Market/MTF (if enrolled to a Market/MTF). The returned and rejected standard nomenclature will be provided by the Government. The return of a referral to the Market/MTF is considered processed to completion.
4.4.4  The contractor shall provide a report of all rejected/returned referrals. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.4.5  The contractor shall advise the patient, referring Market/MTF, and receiving provider of all approved referrals and authorizations including, but not limited to, the following:
•  The Market/MTF single Point of Contact (POC) shall be advised via HIPAA-compliant 278 response. (The Market/MTF single POC may be an individual or a single office with more than one telephone number.)
•  The contractor shall provide a response to the Market/MTF single POC via fax or other approved Government system, if the Government’s or contractor’s HIPAA-compliant 278 system is not available.
•  The notice to the beneficiary shall contain the Referral Case Number or UIN and information necessary to support obtaining ordered services or an appointment with the referred to provider.
•  The notice shall also provide the beneficiary with instructions on how to change their provider, if desired, and will instruct the beneficiary to notify the contractor of the change.
4.4.5.1  The contractor shall make appropriate modifications within their portal, if they are informed that the beneficiary changed the provider listed on the referral.
4.4.5.2  The contractor shall make appropriate modifications to the issued authorization, if the contractor is informed that the beneficiary changed the provider listed on the referral or authorization. The revised referral or authorization shall contain the same level of data as the initial referral or authorization. The revised authorization shall be issued to the beneficiary, the provider beneficiary chose, referring provider and the Market/MTF.
4.4.5.3  The contractor shall not send beneficiary notification letters for referrals marked “urgent.”
4.4.5.4  The contractor shall provide a notification to beneficiaries that failure to adhere to a referral will result in the care being subject to POS charges. In other cases, a referral may be to the civilian provider network, and again, POS charges would apply to a failure to follow the referral.
4.4.5.5  A major purpose of preauthorization is to prevent unanticipated coverage determinations, which are sometimes dependent on particular details regarding the patient’s condition and circumstances.
4.4.6  The contractor shall notify the patient by mail, if services are denied, and shall advise the patient of their right to appeal consistent with the TRICARE Operations Manual (TOM).
4.4.7  The contractor shall also notify the referring provider and single Market/MTF POC of the initial denial by HIPAA-compliant 278 response and by mail.
4.4.8  The contractor shall provide the Market/MTF, by HIPAA-compliant 278 response, the updated authorization and clinical information that served as the basis for the new authorization.
4.5  Directed Referrals (CONUS Only)
4.5.1  Directed referrals are expected to be rare and will be reviewed according to paragraph 1.2. The types of acceptable directed care referrals will be in the best interest of the Government for quality, affordable care and military readiness. The process for submitting directed referrals for services will be contained within the MOUs between the Government and the contractor.
4.5.2  Acceptable directed care special situations include, but are not limited to, the following:
4.5.2.1  Clinically urgent/emergent referrals (Administrative reasons should not be used as an “urgent” request justification; although the contractor shall support PCM/Market/MTF in expediting referrals for administrative reasons when needed).
4.5.2.2  Military operationally related referral requests such as referrals to network providers who provide rapid ATC for an ADSM for military operational issues.
4.5.2.3  Retrospective requests, including UCC referrals and emergency department follow-up referrals for beneficiaries while traveling.
4.5.2.4  Continuity of care considerations along with referrals to providers who have special skill sets, an expertise or access to devices or instruments that cannot be met by providers who might otherwise be selected.
4.5.2.5  Beneficiaries have a right to see any network provider and may chose a different network provider by contacting the contractor to request a change to another network provider within the same specialty requested by the referring PCM/Market/MTF.
4.5.2.6  MTF providers or network providers may generate a directed referral for the purpose of obtaining a second clinical opinion; a clinical visit such as this would not be part of a continuity of care determination. Such a referral should be written as an “evaluate only” request.
4.5.2.7  MTF to Veterans Health Administration (VHA) referrals, Integrated Disability Evaluation System (IDES) referrals, terminal leave for ADSM, Temporary Disability Retired List (TDRL), demobilizing Reserve Component (RC) members and beneficiaries transferring enrollment between regions and ADSMs or cadets/midshipmen on extended convalescent leave.
4.5.2.8  Coordination of care for a Permanent Change of Station (PCS) move.
4.5.3  Directed referrals to DoD recognized Centers of Excellence (CoEs) can be made by DC, network and non-network providers for TRICARE Prime and TRICARE Select beneficiaries. The Government will provide the contractor with a list of DoD recognized CoEs.
4.5.4  Private sector care and Market/MTF directed referrals for initial services to a network or non-network provider greater than 100 miles from the Market/MTF or private sector PCM, where specialized treatment, surgical procedure, and inpatient admission is expected, or being requested, require justification from the Market/MTF or private sector PCM to the contractor and coordination between the contractor and TRICARE Health Plan (THP) prior to approval by the contractor.
4.5.4.1  This coordination process is contained within the MOUs between the Markets/MTFs and contractor. The MOU will also contain guidance on types of Market/MTF directed referrals excluded from this policy.
4.5.4.2  This coordination process is contained within the provider agreement/handbook from the contractor. The provider agreement/handbook will also contain guidance on the types of directed referrals excluded from this policy.
4.5.5  The contractor shall accomplish benefit review and medical necessity review, as required by policy, and then coordinate with THP prior to completing the referral and authorization.
4.5.5.1  The contractor may ask THP for guidance on any Market/MTF or network provider-directed referral that meets the intent of this policy.
4.5.5.2  THP will conduct their review and provide a response within two business days.
4.5.6  The contractor shall make and document appropriate determinations considering the justification provided by the Market/MTF for directed referrals to non-network providers. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.6  Referrals from the Contractor to the Market/MTF
4.6.1  The contractor shall provide Market Directors/MTF Directors with web-based ability to review and update their Capability and Capacity (KSA) tables in real time. The Government defines “real time” in this instance as providing the Markets/MTFs with access to view and update their capability and capacity information 24 hours a day/seven days a week (24/7), exclusive of scheduled system maintenance. For reporting requirements, see DD Form 1423, CDRL, in Section J of the applicable contract.
4.6.2  The contractor shall provide a report of referrals from the contractor to the Market/MTF. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.7  TRICARE Prime
4.7.1  The contractor shall process referrals from the civilian sector in accordance with the following procedures:
4.7.1.1  The contractor shall send referrals for TRICARE Prime beneficiaries who are enrolled to the network for whom the Market/MTF has indicated the desire to receive referral requests as indicated by the capability and capacity tables (except for continuity of care, emergency admissions, and traveling out of area).
4.7.1.2  The contractor shall provide referrals to the Government prior to the contractor’s medical necessity and covered benefit review.
4.7.1.3  The Government will provide the contractor a list of Current Procedural Terminology (CPT) codes or International Classification of Diseases, 10th Revision (ICD-10) (or current edition) codes and will assign these a KSA value from 1 (low KSA value) to 10 (highest KSA value). Diagnoses and procedures not listed shall receive a default KSA value of 1.
4.7.1.4  The contractor shall prioritize the highest KSA value referrals for TRICARE Prime patients for assignment to the Market/MTF for care.
4.7.1.5  The contractor shall notify the beneficiary of the accepted referral to the Market/MTF and provide assistance or instructions for obtaining an appointment in the Market/MTF.
4.7.1.6  The contractor shall send referrals to the Market/MTF via a HIPAA-compliant 278, or other process as identified by the Government.
4.7.1.6.1  The request shall contain the minimum data set described in paragraph 5.0 (with the exception of the Referral Case Number/UIN) plus the referring civilian provider’s telephone number, fax number, and mailing address.
4.7.1.6.2  This data set shall be provided to the Market/MTF in plain text with diagnosis or procedure codes.
4.7.1.7  The contractor shall transmit the referrals within 24 hours from date and time of receipt of referral for “urgent priority” and “routine priority” referrals (excluding MTF closures).
4.7.1.8  The Market/MTF will respond and accept or decline to the contractor via HIPAA-compliant 278, or other process as identified by the Government within 24 hours from receipt of the request for “urgent priority” and “routine priority” referrals. Referrals from the contractor to the Market/MTF shall not be transmitted when the MTF is closed.
4.7.1.9  The contractor shall, and the Government may, notify the beneficiary of the Market/MTF acceptance and provide instructions for contacting the Market/MTF to obtain an appointment in instances where the Market/MTF elects to accept the patient.
4.7.1.10  The contractor shall process the referral request as if the Market/MTF declined to see the patient, when no response is received from the Market/MTF in response to the referral request as defined above.
4.7.1.11  The contractor shall forward all referrals for care based on the Capability And Capacity (KSA) table and secondary referrals table (paragraph 1.4), to the Market/MTF. The only exception will be if the continuity of care criteria is met.
4.7.2  The contractor shall provide each Market/MTF with a monthly report. For reporting requirements, see Contract Data Requirements List, DD Form 1423, in Section J of the applicable contract.
4.8  TRICARE Select
4.8.1  The contractor shall provide a process for TRICARE Select beneficiaries the choice of where specialty care or a procedure is received, to include the MTF with capability and capacity of the specialty care or procedure required; based on when the case meets the needs of the Market/MTF provider’s KSAs and where the capability and capacity table indicates the Market/MTF has capacity to accept TRICARE Select beneficiaries.
4.8.1.1  The contractor shall offer such beneficiaries the option of utilizing a Market/MTF when one exists within ATC standards that has the capacity and capability to provide the needed care. This shall include providing the beneficiary with quality and outcomes data, average days to be seen, as well as general information about out-of-pocket costs for comparable MTF and network providers and facilities capable of providing the service.
4.8.1.2  The contractor shall ensure Select beneficiaries are aware of this program.
4.8.2  The contractor shall provide the beneficiary with information to contact to the Government for MTF appointments when the TRICARE Select beneficiary chooses to obtain care at the MTF.
4.8.3  The contractor shall notify the Government via HIPAA compliant 278 transaction when a TRICARE Select enrollee elects to utilize the MTF within 24 hours of electing care at the MTF. Correspondences shall follow the same procedures for the TRICARE Prime referrals from the network to the Market/MTF as outlined in paragraph 4.7.
4.8.4  The Market Director/MTF Director will ensure that the Capability And Capacity (KSA) tables are continually maintained and refreshed every business day. Referrals for high-value KSAs must be accepted by the DCS in accordance with the capability and capacity tables unless listed in contingency paragraph 8.0.
4.9  Status of Referrals When Beneficiaries Change Geographical Location
4.9.1  The contractor’s referral process shall support continuity of referrals when beneficiaries change geographical region. Changing of geographical region includes both internal contract region and a change to the other T-5 region.
4.9.2  Referrals shall remain valid when a beneficiary changes geographical region, so long as they are still in a Prime Service Area (PSA) (or TPR or TPRADFM) at the new location.
4.9.3  The gaining contractor shall not require a new referral from a PCM in the gaining location.
4.9.4  The contractor shall assist the beneficiary (or IRMAC/RAC) in finding a qualified provider and arranging an appointment with that provider in the new location with the goal of the beneficiary not having disruptions or waiting for care in the new location.
4.9.5  At beneficiary (or the beneficiary’s provider) request, the contractor shall assist with requirements of paragraph 4.9.4, prior to the beneficiary moving.
4.9.6  In the event of a regional change:
4.9.6.1  The gaining contractor shall not require a new referral from a PCM in the gaining location.
4.9.6.2  The gaining contractor shall complete requirements of paragraphs 4.9.4 and 4.9.5.
4.9.6.3  The losing contractor shall retain responsibility for the beneficiary referrals during the period of the move until the beneficiary changes their enrollment to another contractor and coverage becomes effective in the new location.
4.9.6.4  The losing contractor shall ensure the beneficiary has access to urgent care utilizing virtual health during their move, if this service is not offered by the losing Market/MTF.
4.9.6.5  The losing contractor shall forward approved referrals to the gaining contractor when requested (in phone or writing) by the beneficiary or gaining contractor. The information forwarded shall include, but is not limited to, the number of authorized visits and approved diagnostic/treatment codes.
4.9.6.6  The contractor with which the beneficiary is enrolled at the time the referral is activated shall ensure claims are processed appropriately.
5.0  RETURNED/REJECTED/PROCESSED REFERRALS
The contractor shall provide a response why a referral was returned/rejected in a HIPAA-compliant 278 transaction. The returned/rejected standard nomenclature will be provided by the Government.
6.0  NOTIFICATIONS
6.1  The contractor shall provide beneficiaries with multiple referral status alerts and notification options, including email, text, web-portal and hard-copy letters (based on means the beneficiary chooses), to promote ATC. The contractor shall educate beneficiaries on options to receive referral, authorizations and notifications.
6.2.1  The contractor shall make a copy of the referral, consult and the authorization letter electronically accessible and printable to the beneficiary in the contractor’s portal regardless of which alert and notification option the beneficiary chooses.
6.2.2  The contractor shall allow the beneficiary to opt in to hard copy, mailed authorizations and notifications on referrals.
6.2.3  The contractor shall note what preference a beneficiary chooses, hard copy or electronic, as the means of providing authorization and denial letters and change preference upon beneficiary request.
6.2.4  The contractor shall mail all denial letters to the referring provider and beneficiary.
7.0  REPORTS
7.1  The contractor shall locate related referrals, authorizations and claims using the Referral Case Number/UIN.
7.2  The contractor shall modify generated Market/MTF reports to accommodate the Referral Case Number/UIN and NPI. The Referral Case Number/UIN shall also be used for all related customer service inquiries. Referral Case Numbers/UINs and NPIs will be attached to all Market/MTF referrals and will be portable across all regions of care. The Referral Case Number/UIN will be used to match claims to a Market/MTF-generated referral.
7.3  The contractor shall capture the NPIs from the referral transmission report and forward the NPI and corresponding Referral Case Number/UIN to the referred to provider on all referrals.
7.4  The contractor shall provide a report on all specialty referrals. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
8.0  CONTINGENCY OPERATIONS (OPS) WHEN SYSTEMS ARE DOWN
The contractor shall develop a contingency process for transmitting referrals and authorizations when its RM system is inoperable.
8.1  The contingency process will be mutually agreed upon by the Government and the contractor.
8.2  The Government will submit referrals and authorizations utilizing manual fax or the contractor’s portal when the Government RM systems are inoperable. When both the Government’s referral management system and the contractor’s referral management system, simultaneously are inoperable, manual fax shall be used as a last option.
8.2.1  The contractor shall enter referral received via manual fax into its RM system.
8.2.2  Urgent referrals may be transmitted to the contractor immediately during Government RM system downtime.
8.2.3  Markets/MTFs will hold routine referrals and authorizations for two business days when Government RM system is inoperable.
8.3  The contractor shall provide training on submitting referrals within their portal to Markets/MTFs to facilitate referral processing during Government system outages.
9.0  VHA REFERRALS
9.1  The contractor shall comply with requirements pertaining to VHA medical facilities as specified in the TPM, Chapter 1, Section 8.1.
9.2  The contractor shall process DoD to VHA referrals regardless of facility design.
- 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.

v4.8.7983.18738

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.