TRICARE Prime is a managed care option. TRICARE Prime enrollees receive most of their care from an assigned primary care manager (PCM) at a military treatment facility (MTF), if available, or from the TRICARE network. The PCM provides and coordinates care, maintains patient medical records, and refers patients to specialists, if necessary. Specialty care referred by the PCM must be arranged and approved by Humana Military Healthcare Services, Inc. (Humana Military). Primary, routine, and preventive care are provided by the assigned PCM unless the PCM issues a referral.
Eligibility for TRICARE Prime
TRICARE Prime is available to active duty service members (ADSMs) and their families, retired service members and their families, eligible former spouses, and survivors under age 65, as well as individuals age 65 or older who are not entitled to premium-free Medicare Part A.
National Guard and Reserve members and their families may be eligible for TRICARE Prime in certain circumstances. See the TRICARE Eligibility section of this handbook for instructions on how to verify patient eligibility.
TRICARE Prime Enrollment Card
Beneficiaries enrolled in TRICARE Prime receive TRICARE Prime enrollment cards. These cards are not required to obtain care but do contain important information for the beneficiary. Figure 4.1 shows an example of the TRICARE Prime enrollment card.
Figure 4.1 TPR Enrollment Card
In addition to their TRICARE Prime enrollment card, TRICARE Prime beneficiaries should present their uniformed services identification (ID) card or Common Access Card (CAC) at the time of service. Only the uniformed services ID card or CAC may be used to verify eligibility for care. Providers must verify eligibility by selecting “MyHMHS for Providers” or by visiting PGBA. Eligibility is also verified as part of the prior authorization process. See the TRICARE Eligibility section of this handbook for more information about verifying eligibility.
Primary Care Manager
TRICARE Prime enrollees are assigned a PCM who provides and coordinates care, maintains patient medical records, and refers patients to specialists, if necessary. According to TRICARE, a PCM who is practicing within the governing state’s rules and regulations may be a provider of primary care services when rendering services within a TRICARE Prime Service Area (PSA) location, or in those areas where the TRICARE Prime Remote (TPR) benefit is offered. This includes the following PCM types:
A TRICARE Prime beneficiary relies on his or her PCM for referrals to specialty care providers and services either at an MTF or within the local network. For these services to be covered by TRICARE, the network PCM must submit a referral request. There is no requirement for a PCM referral and/or authorization for these services:
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Those provided by the selected, assigned, or on-call PCM in his or her office
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The first eight visits for outpatient behavioral health care services provided by a network provider in a fiscal year (October 1–September 30).* (After the initial eight outpatient behaviorsal health care visits, prior authorization and medical necessity reviews are required.)
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Emergency care
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Clinical preventive services from a TRICARE network provider*
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Services received while the beneficiary was using the point of service (POS) option
*Excludes ADSMs, who always need a referral to receive care outside of the MTF. Certain types of behavioral health care providers also always require a referral. See the Behavioral Health Care Services section of this handbook for additional information.
See the Important Provider Information section of this handbook for descriptions of specific PCM roles and responsibilities.
TRICARE Prime beneficiaries may be reimbursed for reasonable travel expenses for medically necessary care if a health care finder (HCF) authorizes a referral to a specialist who is located more than 100 miles away from their PCM’s office. TRICARE Prime enrollees are required to obtain all care from their PCM unless referred to another TRICARE-authorized provider. Beneficiaries will be referred to a TRICARE network provider based upon availability per the TRICARE access standards. A referral to a non-network TRICARE-authorized provider will only occur if a TRICARE network provider is unavailable.
ValueOptions will issue behavioral health referrals on a case-by-case basis. Refer to the Health Care Management and Administration section of this handbook for more information about referrals and authorizations. For specific inpatient cost-shares, visit the TRICARE Web site.
TRICARE Prime Point of Service Option
A TRICARE Prime beneficiary who utilizes the point of service (POS) option may self-refer to any TRICARE-authorized (network or non-network) provider for medical or surgical services without a referral from his or her PCM. For behavioral health services, the POS option applies when the TRICARE Prime beneficiary receives nonemergency services from a nonnetwork provider. Although a referral is not required when using the POS option, certain prior authorization requirements still apply.
The beneficiary will pay a deductible and 50 percent of the TRICARE-allowable charge. There is no catastrophic cap protection when using the POS option. Special considerations apply if the beneficiary has other health insurance. It is important to note the provider’s reimbursement remains unchanged, but the beneficiary will pay a larger portion of the total TRICARE-allowable charge. Also, it is important for providers to note the end date of referrals and to advise beneficiaries when additional referrals are required.
Note: ADSMs may not use the POS option. ADSMs always need a referral to receive care outside of the MTF.
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