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, the contractor shall ensure all
members of the group practice are TRICARE-authorized providers.
1.1.2 The Defense Health Agency (DHA)
considers the following types of individual professional providers
as primary care providers and the contractor shall designate them
as 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. The contractor shall
ensure PCMs refer TRICARE Prime enrollees 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, the contractor may accept a request
for preauthorization from the network provider in lieu of PCM referral.
If the enrollee fails to obtain a PCM referral when one is required,
the contractor shall pay for the service under Point of Service
(POS) procedures with a deductible for outpatient services and cost-shares
for in- and outpatient services.
1.3 The contractor
shall ensure the PCM notifies the contractor that a referral is
being made. The contractor shall assist the TRICARE 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.
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 SUD visits.