US Family Health Plan Referral Process

Referrals were first required to be submitted to the health plan starting October 1, 2023. On November 1, 2024, we launched the next phase of a new technology solution for managing referrals through our Provider Portal, ProAuth.

This process ensures timely, coordinated care for members and helps reduce administrative challenges for providers. Submitting referrals ensures claims process at the standard TRICARE Prime benefit level, minimizing higher out-of-pocket costs for members.

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 (PCPs)
• Specialists (cannot self-refer, but may refer to other specialists)

Note: Specialists may submit a referral on behalf of the PCP if they have received a referral order from the PCP, but the referral is not yet on file in ProAuth. Please note that when submitting the request in ProAuth, the specialist should list the PCP as the referring provider.

Members cannot submit referrals themselves.

Referral Exempt Provider Types

The following provider types do not require a referral. Services provided by these participating provider types are referral-exempt unless explicitly stated otherwise:

• Advanced Practice Midwife
• Anesthesiology / Nurse Anesthetist / 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 rendered by a participating provider:

• Annual Routine Physicals
• Diagnostic Services (Imaging, labs, pathology, etc.)
• Durable Medical Equipment
• Home Health & Hospice
• Home Infusion
• Nuclear Medicine
• Orthotics & Prosthetics
• Outpatient Behavioral Health services with Participating Providers
• Physical, Occupational, and Speech Therapy
• Prescription Drugs / Part B Drugs
  
• Routine and Specialty OB/GYN services
  
• Routine Ophthalmology / Optometry services
  
• Services provided by the PCP or the covering provider/midlevel in the PCP office
  
• Urgent Care & Emergency Room Visits
  • Note: Follow-Up care after an ER visit may require a referral. Members should consult their PCP for coordination of follow-up specialty care.

Note, authorization requirements still apply. In situations where the service requires authorization, (e.g. adjunctive dental, inpatient care, services specified as authorization required in the benefit repository) the provider should submit an authorization request with supporting clinical documentation.

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 for services to be considered covered under the standard TRICARE benefit.

Network providers:

Your referral covers all of your specialists 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 specific specialist at the office location requested.

• Network Providers: You must send the referral for specialty care directly to in-network specialists and provide a copy to your patient. In-network referrals may be submitted via the ProAuth system, but ProAuth submission is not required.

• Non-Network Providers: You must submit all requests for medically necessary services that cannot be provided within our network must be submitted via our ProAuth system and must be pre-authorized by the Plan. Without pre-authorization, patients will incur substantially higher out-of-pocket costs, including a $300 individual deductible and 50% coinsurance.

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. Care received at an Urgent Care or Emergency Department does not require a referral.

Non-contracted providers: 

Please reach out to the PCP for a referral if you do not have an approved 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/preventive care.

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.

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.

Extensions: If a referral needs to be extended for ongoing specialty care, an extension can be requested tied to the original 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 for information on how to view referrals.

• Specialists: Please call the MPHC referral line at 1-877-542-2654 for support.