TRICARE Prime is a managed care option available in TRICARE Prime Service Areas (PSAs). A PSA is a geographic area where TRICARE Prime benefits are offered. It is typically an area around a military hospital or clinic or other predetermined area. ADFMs and other eligible beneficiaries may enroll in TRICARE Prime or use TRICARE Select. Each TRICARE Prime enrollee is assigned a Primary Care Manager (PCM).
Whenever possible, a PCM located at a military hospital or clinic is assigned, but a TRICARE network PCM may be assigned if a military hospital or clinic PCM is not available.
In most cases, a TRICARE Prime enrollee must obtain a referral and/or prior authorization to receive non-emergency care from a provider other than his or her PCM. All TRICARE Prime enrollees (except ADSMs) can self-refer to a network provider who is authorized under TRICARE regulations to see patients independently for behavioral healthcare services.
A military hospital or clinic has the Right of First Refusal (ROFR) for TRICARE Prime referrals for procedures requiring prior authorization, provided the military hospital or clinic is able to deliver the service requested by the beneficiary's civilian provider. This means TRICARE Prime enrollees must first try to obtain care at military hospitals and clinics.
Military hospital or clinic staff members review the referral to determine if they can provide care within access standards. If the service is not available within access standards, the military hospital or clinic refers the beneficiary to a TRICARE network provider.