Military Health System

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).

1.2  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.

2.1  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.

2.5  Physical Therapy/Occupational Therapy (PT/OT) services referred by a network podiatrist as set forth in Chapter 8, Section 11.1, paragraph 2.5.