TRICARE program: referrals and preauthorizations under TRICARE Prime

10 U.S.C. § 1095f
in effect
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(a) Referrals.—(1) Except as provided by paragraph (2), a beneficiary enrolled in TRICARE Prime shall be required to obtain a referral for care through a designated primary care manager (or other care coordinator) prior to obtaining care under the TRICARE program. (2)(A) The Secretary may waive the referral requirement in paragraph (1) in such circumstances as the Secretary may establish for purposes of this subsection. (B) The Secretary shall waive the referral requirement in paragraph (1) in the case of a member of the armed forces serving on active duty who seeks to obtain any of the following kinds of care in a military medical treatment facility:(i) Physical therapy. (ii) Nutritional. (iii) Audiological. (iv) Optometric. (v) Podiatric. (3) The cost-sharing amounts for a beneficiary enrolled in TRICARE Prime who does not obtain a referral for care under paragraph (1) (or a waiver pursuant to paragraph (2) for such care) shall be determined under section 1075a(c) of this title. (b) Preauthorization.—A beneficiary enrolled in TRICARE Prime shall be required to obtain preauthorization only with respect to a referral for the following:(1) Inpatient hospitalization. (2) Inpatient care at a skilled nursing facility. (3) Inpatient care at a rehabilitation facility. (4) Inpatient care at a residential treatment center. (c) Prohibition Regarding Prior Authorization for Certain Referrals.—The Secretary of Defense shall ensure that no contract for managed care support under the TRICARE program includes any requirement that a managed care support contractor require a primary care or specialty care provider to obtain prior authorization before referring a patient to a specialty care provider that is part of the network of health care providers or institutions of the contractor.

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