Important update: Referral requirements & ProAuth system implementation for US Family Health Plan.

ProAuth referral management system update

As part of our ongoing efforts to enhance care coordination and streamline referral management, we announced phase one of a new technology solution for managing referrals through our Provider Portal, ProAuth, on November 1, 2024. The next phase of this solution will go live for dates of service on or after May 1, 2025. Beginning on this date, all specialty care claims will require a valid referral recorded in the ProAuth system to process at the standard TRICARE^® Prime benefit level.

IMPORTANT NOTE: Previously submitted referrals for ongoing services that were not originally sent through the ProAuth system must be resubmitted through ProAuth to avoid higher member cost shares.

Key information

1. ProAuth System Use: To avoid much higher member cost shares, all referrals for specialty care for dates of service on or after May 1, 2025 must be submitted through the ProAuth system prior to the member receiving care. This requirement applies to both new and established patient visits. Please refer to the referral program page for more information about exempt provider types and services (e.g., urgent and emergent services do not require referrals).
2. Impact on Claims Payment: The US Family Health Plan offers two benefit levels: the Standard TRICARE Prime benefit and the Point of Service (POS) option, which includes a deductible and 50% coinsurance. To avoid the claim being processed at the POS Benefit level—resulting in higher member cost share—it is essential that all referrals be accurately entered into the ProAuth system before the member receives specialty care.
3. Registration: To access the ProAuth system, providers must have an active account. Providers can request an account through their organization’s Local Administrator. If your organization does not have a Local Administrator, one can be appointed by completing the registration form.
4. Training and Resources: After logging into ProAuth, providers will have access to user guides and training videos. For additional training or assistance, please contact [email protected] to schedule a virtual session. You can also visit our referral program page for the latest FAQs and resources.

Ensuring a seamless process

We understand that changes to the referral process may raise concerns for your patients. Our ProAuth system is designed to make referral submission as straightforward as possible, ensuring a seamless experience for both providers and members. For in-network care, referrals submitted through ProAuth will typically process efficiently, avoiding delays or unexpected costs for your patients.

Thank you for your continued support and partnership in delivering high-quality care to our members, your patients.