TRICARE Prime beneficiaries have a wide variety of preventive and routine services available to keep them healthy and help identify potential problems down the road. It is therefore important to understand the differences between preventive and routine health care and how TRICARE covers each.
Preventive Services
Preventive services are a covered benefit to help beneficiaries stay healthy. Preventive care includes
diagnostic procedures, such as cancer and cardiovascular screenings, hearing screenings (for high-risk neonates), immunizations, well-child care and infectious disease screenings.
There are limitations on the frequency of preventive care, and coverage varies depending on whether a beneficiary is using TRICARE Prime, TRICARE Standard or TRICARE Reserve Select. Preventive services are provided without referrals, except when active duty service members seek care from civilian providers.
Routine Services
TRICARE defines routine care as any care that is not for an urgent or emergency situation. Routine
services may be covered if there is an underlying medical necessity and if the service is covered by TRICARE.
Some of the routine services covered by TRICARE include individual provider services (e.g., office visits, consultations, diagnosis and treatment by specialists), allergy testing and treatment, osteopathic manipulation (except for chiropractic care), rehabilitation services and medical supplies used within the office.
A referral or authorization may be required for some routine services. View the
referral and authorization requirements and
request a referral or authorization if necessary.
When billing for these services, remember that TRICARE coverage is based on medical necessity, and
diagnoses should reflect that. Be sure to use the correct Current Procedural Terminology (CPT®) and ICD-9 codes hen billing and choose a specific diagnosis.
For more information about preventive and routine health care services, refer to the “
Medical Coverage” section of your TRICARE Provider Handbook
