US Family Health Plan Referral Process
The US Family Health Plan covers specialty care through two benefit levels:
- The standard TRICARE® Prime benefit
- The Point-of-Service (POS) option
Specialty care with an in-network provider is covered at the TRICARE Prime level and does not require plan approval.
If a member chooses to receive care from a non-participating (out-of-network) provider, they may do so without prior approval, but the services will be processed under the POS benefit level, resulting in higher out-of-pocket costs.
Alternatively, if a provider determines that care from a non-network provider may be medically necessary- for example, when there is no available or appropriate in-network option- they may submit a prior-authorization request through ProAuth. If approved, the services will be processed under the standard TRICARE® Prime payment methodology and member cost share.
Frequently Asked Questions
General referral FAQs for providers
List of frequently asked questions from providers regarding the new referral process for USFHP.
Beginning June 2, 2025, all specialty care provided by non-participating (out-of-network) providers must have an approved authorization to process at the standard TRICARE® Prime benefit level.
Primary Care Providers (PCPs) and participating specialists may submit requests for specialty care outside of the network.
Referral Exempt Providers
Referrals are not required for services provided by the following participating provider types, unless otherwise specified:
- Advanced Practice Midwife
- Anesthesiology / CRNA / Anesthesiologist Assistant
- Clinical Nurse Specialist
- Emergency Medicine
- Nurse Practitioners
- Obstetrics & Gynecology
- Optometrist / Ophthalmology
- Pathology
- Physicians Assistants
- Psychiatric / Mental Health Practitioner
- Radiology
Referral Exempt Services
The following services are referral-exempt when provided by a participating provider:
- Annual Routine Physicals
- Diagnostic Services (e.g., imaging, labs, pathology)
- Durable Medical Equipment
- Home Health & Hospice
- Home Infusion
- Nuclear Medicine
- Orthotics & Prosthetics
- Outpatient Behavioral Health
- Physical, Occupational, and Speech Therapy
- Prescription Drugs & Part B Drugs
- Routine and Specialty OB/GYN
- Routine Ophthalmology / Optometry
- Services from the PCP or the covering midlevel provider
- Urgent Care & Emergency Room Visits
- Note: Follow-up care after an ER visit may require a referral.
Important: Authorization may still be required for certain services (e.g., inpatient care, adjunctive dental). Please check the benefit repository and submit supporting documentation when needed.
- Network Providers: The referral applies to all of the specialist's participating locations. If care is provided at a non-participating site, a new referral is required.
- Non-Network Providers: Referrals are specific to the named specialist and their exact office location, as listed in the authorization letter.
- To Network Providers: Submit the referral directly to the specialist and provide a copy to the member. Submission through ProAuth™ is optional.
- To Non-Network Providers: Submit a request for a Prior Authorization via ProAuth™ for medical necessity review. In-network approval is required to avoid higher member costs (e.g., $300 deductible, 50% coinsurance).
We adhere to TRICARE® timeliness policies and regulations:
- Network Providers: Referrals requests for in-network specialty care submitted in ProAuth™ will be reviewed within two (2) business days.
- Non-Network Providers: Prior Authorization requests for out-of-network specialty care (medical necessity review) will be completed within 14 calendar days.
Providers
- Network Providers: In-network referral status can be viewed and printed in ProAuth™ if submitted to the plan.
- Non-Network Providers: You will receive mail notifications regarding the Prior Authorization decision.
Members
Decisions can be viewed in the USFHP Member Portal. Denial letters will also be mailed to members.
- Network Providers: If no referral has been received from the PCP, the member may still receive care under the standard TRICARE Prime benefit level.
- Non-Network Providers: Contact the referring provider. If a referral is not available before the service, the care will be considered self-referred, and POS cost shares will apply, unless the service is referral-exempt.
- Referral: A request for specialty care, typically from a PCP. It does not determine medical necessity.
- Authorization: A determination that a service is medically necessary and a covered benefit.
- Approved: The service will be processed at the standard TRICARE® Prime benefit level.
- Denied: For covered services, the member may still seek care under the POS (point-of-service) option, subject to higher out-of-pocket costs.
To avoid member cost-share implications, we ask providers to make their best effort to submit referrals in advance. This helps ensure timely claims processing and the best member experience.
- Providers can use ProAuth for retroactive requests up to 120 days from the date of service.
- For requests 120 days from the remit date of a claim, contact us directly for assistance.
To enroll, visit the ProAuth™ Enrollment Page or contact your Provider Relations Representative for account setup and training at [email protected].
Members
If you don’t see a referral in the Member Portal, please contact your PCP or referring specialist to make sure they submitted a referral.
Providers
- Requesting Providers: Please see ProAuth™ FAQs for information on how to view referrals.
- Specialists: Please call the MPHC referral line at 1-877-542-2654 for support.
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