US Family Health Plan Referral Process

The new referral process begins with dates of services starting October 1, 2023.

ProAuth has been accommodating referrals to non-network specialists since October 1, 2023.

You can enter referrals to network specialists starting November 1, 2024.

Primary care providers and specialists (specialists cannot self-refer but can refer to other specialists). Members cannot submit their own referrals.

Except for the services listed below, all specialty care requires a referral.

The following services do not require a referral (please confirm authorization requirements):

Preventative services/providers

• Annual physicals and preventative care
• Obstetric/gynecological services (routine and specialty visits) from participating providers
• Ophthalmology/optometry (routine and specialty visits) from participating providers
• Services provided by the primary care provider (PCP) (or the covering provider/midlevel in the PCP office)

Non-preventative services*

• Behavioral mental health care from an office-based participating provider
• Dental services
• Durable medical equipment and medical supplies
• Home health/hospice
• Home infusion
• Inpatient services
• Life-threatening emergencies
• Orthotics and prosthetics
• Physical, occupational, and speech therapies
• POS-exempt services, as listed in the benefits and eligibility portal
• Urgent care
• Wigs/hairpieces

*If it is medically necessary for the above services to be performed at an out-of-network location due a limited network, the provider can request authorization for services to be considered covered under the standard TRICARE benefit.

• Network providers: Your referral covers all of your specialist’s network locations. If a network provider needs to provide care at a non-participating location, you must submit a new referral.
• Non-network providers: Your referral covers only the provider office requested.

Starting November 1, 2024, network and non-network referrals can be submitted through ProAuth.

Martin's Point must adhere to TRICARE timeliness policies and regulations, which specify a maximum turnaround of two business days.

Providers: In Proauth.

• A letter will be mailed to the provider only if a referral is denied.
• Letters to non-network specialists will be mailed for approved non-network referrals.

Members: In the USFHP Member Portal. A letter will be mailed to the member only if a referral is denied.

Contracted providers: If you received a referral from the PCP but it is not in ProAuth, the specialty provider’s office can enter the referral into ProAuth on the PCP’s behalf. If there is no record of a referral, the beneficiary can receive care under the Point of Service (POS) Option with a higher cost share.

Non-contracted providers: Please reach out to the PCP for a referral if you don’t have a referral on file. If you are unable to get a referral prior to service, the service will be considered self-referred and the POS cost share will apply, unless the service is an exclusion listed above. (See How do I know if a beneficiary needs a referral?)

Authorization: This is a determination as to whether a service is medically necessary and a covered benefit. Typically, authorizations are requested by the provider rendering the service.

Referral: This is a request for specialty care; not a determination of medical necessity. Typically, referrals are requested by PCPs for consultation and potentially for ongoing specialty care. A referral does not replace authorization or the need to meet coverage requirements.

Approved referrals apply to in-network/contracted co-pays and cost shares. When a referral is denied, a member has the option to use the point-of-service (POS) benefit, and the denied referral will be used to apply the POS deductible and cost shares.

No. Referrals should be submitted in ProAuth.

Please find more information about our ProAuth portal here.

A physician or mid-level who doesn’t provide primary care/preventative care.

Yes. We must receive these referrals within 120 days of the remit date.

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.

Participating and non-participating providers should make sure they have access to ProAuth. ProAuth access is typically managed by a representative in your organization who is your local administrator. Please contact your supervisor or local administrator to set up access. If your organization doesn’t have a local administrator, please sign up online.

You must have a referral in the ProAuth system. Referrals can be approved for up to 12 months. A specialist providing ongoing care can enter a referral into ProAuth on behalf of the referring provider.

Renewals: If a referral needs to be renewed for ongoing care, please extend the existing referral for another 12 months. This will maintain the same referral number.

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; how to view referrals.
• Specialists: Please call the MPHC referral line at 1-877-542-2654 for support.