TRICARE and You: Specialty Care Referrals

If you need specialty care for a medical procedure, you’ll normally be referred by your primary care manager to a specialist. It’s important that you manage it correctly so that you get the care you need, don’t incur any out of pocket costs, and record it properly. Read the full blog to understand how to get a specialty care referral from your primary care manager.

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This blog is the most recent in a series helping members of the Coast Guard family understand how to use their TRICARE benefits. The blog series will continue every Monday, right here on Coast Guard All Hands.

Written by Cmdr. Paul Fawcett

If you need specialty care for a medical procedure you’ll normally be referred by your primary care manager to a specialist. It’s important that you manage it correctly so that you get the care you need, don’t incur any out of pocket costs, and record it properly.

Referrals for Active Duty Members

If you’re an active duty member assigned to a Coast Guard Clinic and need specialty care you may be referred to a TRICARE network civilian provider or to a Military Treatment Facility. When you receive your referral you are normally given the name of a provider to see and you are responsible for making an initial appointment within a set period, normally 30 days. If you don’t schedule your appointment within that period, it’s no longer valid and you’ll need to go back to the clinic for a new appointment. From the date you call the specialty provider, they must schedule your appointment within 28 days according to TRICARE policy. If you are referred to a military treatment facility you may be told when your appointment is.

When you have your appointment, ask your provider to send copies of your treatment notes to your servicing Coast Guard Clinic to put into your medical record. It’s very important that your treatment be documented.

Referrals for Dependents and Retirees

Specialty care referrals for dependents and retirees depend on which TRICARE plan you are enrolled to. Beneficiaries enrolled to TRICARE Standard do not need referrals for non elective procedures. However, specialty care copays do apply. TRICARE Prime beneficiaries do require referrals for specialty care. If you seek specialty care without a referral and you are enrolled to TRICARE Prime, you may be responsible for out of pocket costs for the treatment.

Specialty providers are required to provide an appointment within 28 days of your call to schedule it. However, if you are offered an appointment within that period and decline it, the provider has met the requirement and is no longer responsible for meeting the 28 day standard.

FAQs

Q: I have a particular local doctor I want to see for my specialty care. Can I do that?
A: You may be able to see a particular provider if they are TRICARE approved, accept your plan, are accepting patients, and agree to see you. If not, you may not be able to see them or may responsible for out of pocket costs if you do so without a referral.

Q: I have a particular doctor I want to see for specialty care that is geographically distant from where I live or am stationed. Can I do that?
A: You can be referred to any specialist that accepts your TRICARE plan and will see you. You would receive no travel reimbursement for a trip to specialty care when that same care is available locally.

Q: I have a specialty doctor I want to see that doesn’t accept TRICARE. Can I see them?
A: You cannot be referred to a non TRICARE approved doctor. If you visit one you may have to pay out of pocket costs.

Q: My condition is urgent. Will I have to wait 28 days for my specialty appointment?
A: No. Your primary care doctor can mark your referral as needing care more quickly and it can be processed and scheduled faster depending on the urgency.

For more information about TRICARE specialty referrals please visit www.tricare.mil. You can also contact a Coast Guard Health Benefits Administrator at 1-800-9-HBA-HBA or CGHBA@uscg.mil.

Have more questions? Leave a comment below!

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