A second opinion is when a physician, other than the one previously seen by a beneficiary, gives his or her view about the beneficiary’s health condition and how the condition should be treated. The second opinion does not include the treatment itself. Getting a second opinion can help the beneficiary make a better informed decision about his or her care. For example, the specialist has suggested surgery for tennis elbow, and the beneficiary isn’t sure if he or she is ready to take that step. The beneficiary has the right to request an office visit with another provider for a second opinion.
Who can request a second opinion:
- primary care managers (PCMs)
- any other provider
*Active duty service members (ADSMs) must coordinate second opinions with their PCM. Although non-active duty services members can self-refer for second opinions, the TRICARE Prime travel benefit may only be available if the nearest appropriate specialist is more than 100 miles each way from the PCM's location. See TRICARE's Prime Travel Benefit page for additional information.
What if the second specialist suggests physical therapy instead of surgery? When two providers give different opinions, TRICARE allows a third opinion. The third specialist’s opinion is not a tie-breaker, but rather one more opinion to consider before making a final decision. If the two providers’ opinions are similar, a beneficiary-initiated request for an office visit from a third physician is covered.
Second and third opinions may require approval from Health Net Federal Services, LLC (HNFS). See the Prior Authorization, Referral and Benefit tool to determine if an approval is required based on your TRICARE plan.
An approval from HNFS covers the initial evaluation and diagnostic services, but not treatment, and is valid for a specific length of time as stated on the approval letter.
Any treatment beyond the evaluation and follow-up visit may require an approval for all TRICARE Prime beneficiaries. TRICARE Prime beneficiaries, excluding ADSMs, who see a network or non-network provider without an approval from HNFS will choose to use their Point of Service option.