1.0 Policy
1.1 TRICARE
Prime enrollees shall select or have assigned to them PCMs according
to guidelines established by the
Market/Military
Medical Treatment
Facility (MTF)
Director and Director,
TRICARE Regional Offices (TROs).
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. 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 a Market/MTF 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.