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 their 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.
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 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 TRICARE Prime enrollees.
2.4 Outpatient, office-based, mental
health and SUD visits.
2.6 TRICARE Prime-enrolled
dual eligible, to the extent practicable, should follow all TRICARE
Prime requirements for PCM 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.