The US Family Health Plan covers specialty care through two benefit levels:
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.
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.
Referrals are not required for services provided by the following participating provider types, unless otherwise specified:
The following services are referral-exempt when provided by a participating provider:
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.
We adhere to TRICARE® timeliness policies and regulations:
Decisions can be viewed in the USFHP Member Portal. Denial letters will also be mailed to members.
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.
To enroll, visit the ProAuth™ Enrollment Page or contact your Provider Relations Representative for account setup and training at [email protected].
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.
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