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 Primary
Care Providers (PCPs) 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 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 shall
refer the enrollee to another
primary
care provider PCP. 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.