Prior Authorizations and Referrals

What if I need to be seen today?

If you are enrolled in TRICARE Prime you must first contact your primary care manager (PCM). If you cannot get care from your PCM, he or she must submit a referral to Health Net for civilian urgent care services. TRICARE Standard beneficiaries do not require a referral. Learn more on our emergent and urgent care page and referral and authorization requirements.

What is the difference between a prior authorization and referral?

Learn more about the differences on our Prior Authorizations and Referrals page.

How do I request a new prior authorization or referral?

TRICARE requires a provider, typically your primary care manager or family doctor, to submit prior authorization and referral requests. TRICARE Standard beneficiaries can self-refer. Please contact your provider and have him or her submit your request.

Why was I referred to a military treatment facility for care?

If you live near a military treatment facility (MTF) and are referred for specialty care, inpatient admissions, or procedures requiring prior authorization, Health Net will first attempt to coordinate your care at the MTF. If the services are not available at the MTF, the care will be coordinated with a TRICARE network provider.

Visit our Referrals to MTFs page for additional information.

How can I get prepared for my next doctor's appointment?

It's important to prepare for your next doctor's appointment so you can get the most out of your time with him or her. We have created some appointment tips which include a checklist of the things you might want to ask your doctor and the things that are important for him or her to know.

What if my referral or prior authorization was denied?

Any denied authorization can be appealed. However, the following cannot be appealed:

  • Authorizations approved under point of service.
  • Authorizations redirected and approved to a network provider when a non-network provider was requested.
  • Authorizations redirected and approved to a military treatment facility.


Learn how to file an appeal on our Appeals page.

 

Do I need a prior authorization or referral even though I have other health insurance?

Active duty service members who have other health insurance (OHI) require an approval from Health Net for all services. All other beneficiaries with OHI only require a prior authorization for inpatient behavioral health services. Beneficiaries with OHI need to follow their OHI rules for obtaining care even if those services are not covered by OHI or benefits have been exhausted.

Visit our How TRICARE Works with OHI page to learn more.