Provider Handbook - Primary Care Manager's Role

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Primary Care Manager's Role

TRICARE Prime beneficiaries agree to initially seek all nonemergency services from their primary care managers (PCMs). PCMs are specified providers selected for primary care services at the time of enrollment. The PCM is an individual provider within a military or civilian setting.

The PCM’s roles and responsibilities are as follows:

Primary care services are typically, although not exclusively, provided by internal medicine physicians, family practitioners, pediatricians, general practitioners, and, in some cases, obstetricians/gynecologists.
When a provider signs a contractual agreement to become a PCM, he or she must follow TRICARE procedures and requirements for obtaining specialty referrals and prior authorizations for nonemergency inpatient and certain outpatient services.
In the event the assigned PCM cannot provide the full range of primary care functions necessary, the PCM must ensure access to the necessary health care services, as well as any specialty requirements.
PCMs are required to provide access to care 24 hours a day, seven days a week, including after hours and urgent care services, or arrange for on-call coverage by another provider. Note: The on-call provider must be a certified, network provider who is also a PCM. The PCM or on-call provider will determine the level of care needed:
- Routine care—The PCM or on-call provider instructs the TRICARE Prime beneficiary to contact the PCM’s office on the next business day for an appointment.
- Urgent care—The PCM or on-call provider coordinates timely care for the TRICARE Prime beneficiary.
- The on-call physician should contact the PCM within 24 hours of an inpatient admission to ensure continuity of care.
PCMs referring patients for specialty care may need to coordinate the referral with Humana Military.
ADSMs must have referrals for all care outside of MTFs (except for emergencies or as provided in TPR regulations, if applicable), including all behavioral health care services. If the ADSM has an assigned civilian PCM under TRICARE Prime or TPR, all specialty referral and authorization guidelines must be followed.

Last Update: January 15, 2011