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Creating referrals and authorizations

All referrals and authorizations must be submitted through provider self-service. 

When completing a referral, always include the sponsor's TRICARE ID, diagnosis and clinical data explaining the reason for the referral.

If the patient needs services beyond the referral’s evaluation and treatment scope, the PCM must approve additional services.

All network PCM and specialist-to-specialist referral requests will be directed to system-selected providers or to providers the beneficiary has seen in the preceding six months.

  • The choice of up to five providers will reflect the optimal options in terms of quality of care, accessibility (e.g., appointment availability), affordability and drive time from the beneficiary’s address.
  • If the beneficiary resides within a military hospital’s catchment area (40-mile radius), the services requested may be subject to redirection to that military hospital through the Right of First Refusal (ROFR) process.
Point of Service (POS) Laboratory Developed Tests (LDT) Prior Authorizations

When Point of Service (POS) applies

POS applies when a TRICARE Prime beneficiary:

  • Receives care from a network or non-network TRICARE-authorized provider without a referral from his or her Primary Care Manager (PCM)
  • Receives care for clinical preventive services when they see a non-network provider
  • Self-refers to a civilian specialty care provider after a referral has been authorized to a military hospital or clinic (MTF) specialty care provider
  • Self-refers to a non-network specialty care provider after a referral has been authorized to a network specialty care provider

Using the POS option results in greater out-of-pocket expenses for beneficiaries:

  • Annual deductible (applies to outpatient services only): $300/individual and $600/family
  • Outpatient cost-share: 50% cost-share of the TRICARE-allowable amount after the annual deductible is met (beneficiary may be responsible for up to 15% above the TRICARE-allowed amount for a non-network provider)
  • Outpatient cost-share: 50% cost-share of the TRICARE-allowable amount (beneficiary may be responsible for up to 15% above the TRICARE-allowed amount for a non-network provider)

POS does not apply for services that do not require a referral

POS does not apply for services that do not require a referral such as:

  • Emergency services
  • Preventive care from a network provider
  • Beneficiaries whose OHI is primary
  • Newborn or adoptee care (a newborn or adoptee is covered as a TRICARE Prime/TRICARE Prime Remote Active Duty Family Member (TPRADFM) beneficiary for the first 90 days after birth or adoption, as long as one additional family member is enrolled in TRICARE Prime/TPRADFM or the sponsor is active duty)
  • Active Duty Service Member (ADSM) care (ADSMs who do not coordinate care through their PCM may be responsible for the entire cost of care)
  • Ancillary services such as diagnostic radiology and ultrasound services, diagnostic nuclear medicine services, pathology and laboratory services, or cardiovascular studies (unless part of an episode of care that meets the POS requirements as listed above)

Laboratory Developed Tests (LDT)

TRICARE approves coverage for LDTs to inform and support clinical decision making in the care of our beneficiaries.

Prior authorization requirements

Prior authorization is required for all LDTs except for Cystic Fibrosis (CF) carrier screening and Noninvasive Prenatal Screening for Trisomies, 13, 18, 21, X & Y (NIPT) testing. Note: Expanded NIPT is not covered.

Providers must submit a completed LDT request and attestation for prior authorization and claims payment consideration. CF and NIPT testing, when part of the newborn screening panel, is handled under the global maternity authorization. For the quickest processing to approval for prior authorization, submit the request via provider self-service and attach the required documentation.

Please note that a completed attestation form will be accepted in lieu of supporting clinical documentation for prior authorization requests and claim payment; however, the authorizations are subject to a routine audit that will include a request to provide supporting medical documentation.

For all requests:

  • Include the coverage criteria from the approved LDT list found on Health.mil to support your request 
  • Include complete beneficiary information, diagnoses, CPT codes for the requested tests and the purpose for the testing when requesting prior authorization
  • Providers requesting one of the covered LDTs must use a CLIA-certified laboratory
  • We suggest using Quest or LabCorp to ensure availability of an appropriately licensed lab

Given the complexity of risk assessment and test interpretation, as well as the importance of adequate medical management, genetic counseling is very valuable to any individual receiving a LDT. Genetic counseling may only be provided by TRICARE-authorized providers and must precede the actual LDT. 

Beneficiaries are responsible for the appropriate copay/cost-share on lab claims processed with the approved authorization on file according to their benefit plan. Claims for genetic testing submitted without an approved authorization or LDT request and attestation form will be denied. Other Health Insurance (OHI) rules apply.

Important information

Providers can attach LDT attestation forms to the authorization request in provider self-service by selecting ATTESTATION FORM – LAB DEVELOPED TEST (LDT) in the drop-down menu.

GRAIL Galleri attestation form

Humana Military requires prior authorization for the below services. A reduction in provider payment will be applied for non-compliance with prior authorization requirements. If a beneficiary has Other Health Insurance (OHI) that will be the primary payer, prior authorization is not required by TRICARE. See TRICARE Reimbursement Manual (TRM) Chapter 1, Section 28 for additional information on reduction of payment for non-compliance with utilization review requirements.

Medical services and procedures

  • Adjunctive dental
  • Advanced life support air ambulance in conjunction with stem cell transplantation
  • Amyloid PET scans performed for evaluation of MAB treatment
  • Bariatric surgery
  • Dental anesthesia
  • ECHO services
  • Home health services/home infusion
  • Hospice
  • Laboratory Developed Tests (LDT)
  • Low protein modified foods
  • Monoclonal Antibody Drugs (MAB) for mild cognitive impairment or mild dementia stage of Alzheimer’s disease
  • Open, arthroscopic and combined hip; Surgical for the treatment of Femoroacetabular Impingement (FAI)
  • Spinal fusion, spinal cord stimulators and related spinal procedures
  • Transplants (solid organ and stem cell, not corneal transplant)

Medical inpatient admissions

  • Acute care admissions (notification of acute care admission required by the next working day)
  • Admissions or transfers to Skilled Nursing Facilities (SNF), rehab, Long Term Acute Care (LTAC)
  • Continued stay review
  • Discharge notification

Behavioral health

  • Acute care admissions (notification of emergent acute care admission required by the next working day)
  • Admissions or transfers to detoxification and rehabilitation services
  • Applied Behavior Analysis (ABA)
  • Electroconvulsive Therapy (ECT)
  • Psychoanalysis
  • Residential Treatment Centers (RTC)
  • SpravatoTM
  • Transcranial Magnetic Stimulation (TMS)