TRICARE Referral Guide: How It Works & When You Need One | TRICARE.com

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## Definition A referral is a formal request from your primary care manager (PCM) for you to see a specialist or receive specific medical services not offered within their own office.

## What it means in practice In the TRICARE system—specifically for those enrolled in **TRICARE Prime**—a referral is your "permission slip" to receive specialty care. If you have a skin condition that your PCM cannot treat, they will submit a referral to your regional contractor (Humana Military in the East or TriWest Healthcare Alliance in the West). The contractor then reviews the request to ensure the service is medically necessary and determines if the care should be provided at a Military Medical Treatment Facility (MTF) or a civilian specialist in the network.

If you are enrolled in **TRICARE Select**, you generally do not need a referral for most clinical specialty visits. You can simply find a TRICARE-authorized provider and schedule an appointment. However, certain services like physical therapy, home health care, or ABA therapy still require "prior authorization" regardless of your plan.

Bypassing the referral process can be expensive. If you are a Prime enrollee (non-active duty) and see a specialist without an approved referral, you will be charged under the **Point-of-Service (POS) option**. For the 2026 plan year, this typically includes a $300 individual deductible and a 50% cost-share of the TRICARE-allowable charge. Active duty service members must always have a referral for civilian specialty care; failing to do so may result in the claim being denied entirely, leaving the member responsible for the full bill.

Once a referral is approved, you will receive an authorization letter via your regional contractor’s secure portal or by mail. Use this letter to ensure the specialist is within the network and to confirm how many visits have been authorized.

## Related terms * **Prior Authorization:** A requirement for the regional contractor to review a specific procedure or medication for medical necessity before it is performed or dispensed. * **Primary Care Manager (PCM):** The doctor, nurse practitioner, or physician assistant who coordinates all your healthcare and initiates referrals. * **Point-of-Service (POS) Option:** An expensive cost-sharing track used when TRICARE Prime members see a specialist without a required referral. * **Network Provider:** A civilian healthcare professional who has a contract with Humana Military or TriWest to provide care at a pre-negotiated rate. * **Medical Necessity:** The standard used by TRICARE to determine if a service is appropriate, reasonable, and required for the diagnosis or treatment of an illness or injury.

## Sources * TRICARE.mil - Referrals and Authorizations: [https://www.tricare.mil/referrals](https://www.tricare.mil/referrals) * TriWest Healthcare Alliance (West Region): [https://www.triwest.com](https://www.triwest.com) * Humana Military (East Region): [https://www.humanamilitary.com](https://www.humanamilitary.com)