Administration
Chapter 1
Section 7.1
Primary
Care Managers (PCMs)
Issue Date: May 15, 1996
Revision: C-90, September 3, 2021
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.
A temporary
waiver of the referral requirement for TRICARE Prime enrollees,
not including Active Duty Service Members (ADSMs), for the Coronavirus
2019 (COVID-19) vaccine is authorized. The COVID-19 vaccine is a
clinical preventive service and under this waiver it may be obtained
from any TRICARE Basic (medical) program authorized non-network
provider without incurring POS charges, where applicable. See Chapter 1, Section 15.1.
1.3 The PCM is responsible for
notifying the contractor that a referral is being made. The contractor will
assist the TRICARE 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 TRICARE Prime
enrollees.
2.4 Outpatient, office-based, mental
health and Substance Use Disorder (SUD) visits.
2.6 TRICARE Prime-enrolled
dual eligibles, to the extent practicable, should follow all TRICARE Prime
requirements for PCM assignment, referrals, and authorizations.
However, they are not subject to POS cost-sharing. See the TRICARE
Operations Manual (TOM), Chapter 6, Section 1.
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