TRICARE Referrals and Womack's Right of First Refusal

Under TRICARE Prime, your primary care manager (PCM) coordinates your care. When you need specialty care that your PCM cannot provide, they submit a referral request to Humana Military (the TRICARE East contractor) for authorization and processing.

Once the referral is approved, your regional contractor sends you an authorization letter with specific instructions, and that letter is also available in your region's patient portal. The Defense Health Agency's guidance is that when you get a referral for specialty care, you can expect to get an appointment within 28 days.

Active-duty service members need a referral for most care received outside their assigned military hospital or clinic, including urgent, routine, and preventive care from providers other than their PCM. Other TRICARE Prime enrollees need referrals for specialty care and some diagnostic services.

In the Fort Bragg area, TRICARE Prime enrollees are subject to the Right of First Refusal. This means that when a specialty care referral is submitted, Womack Army Medical Center gets the first opportunity to provide that care before it is sent to a civilian network provider.

Here is the typical sequence: your PCM submits a referral request to Humana Military. The request goes to Womack, which reviews whether it can provide the needed specialty service. If Womack can accommodate you, your referral is directed there. If Womack cannot provide the service, the referral goes out to the civilian TRICARE East network.

This process applies only to TRICARE Prime enrollees. If you are enrolled in TRICARE Select, you are not subject to the Right of First Refusal, and you can book directly with a TRICARE-authorized provider for most care. Two limits survive: applied behavior analysis still requires a referral, and TRICARE lists a set of services that need pre-authorization under Select, so it is worth checking before you schedule.

Once a referral is assigned to Womack Army Medical Center through the Right of First Refusal process, you generally cannot switch to a civilian provider. TRICARE East states that it cannot change the facility that accepts a referral, and that only the military hospital or clinic can do that. A reversal is possible for two stated reasons: continuity of care, or special circumstances that prevent you from using a military hospital or clinic. TRICARE also notes that if you pick a provider before the Right of First Refusal decision and the military facility can provide the service, you have to go to the military facility.

When a referral does go out to the civilian network, your authorization letter names the provider to book with, and TRICARE directs you to your regional contractor if you need to find a different one. That is the civilian-network case, not the Womack case.

For the Womack case, a reversal request starts with Womack itself, because TRICARE East says only the military hospital or clinic can change the facility that accepts a referral. Womack's Referral Management office takes those calls at 910-643-2499. Humana Military, at 800-444-5445, is the number for referral and authorization status questions.

Active-duty service members have the most restrictive referral requirements. Under TRICARE Prime, a referral is required for any care the PCM does not provide, and TRICARE states that this includes urgent, routine, preventive, and specialty care. Urgent care has its own route, and it is not the route for an emergency: if you reasonably believe you have one, call 911 or go to the nearest emergency room, with no referral or pre-authorization needed first. For urgent but non-emergency care, TRICARE tells active-duty members enrolled in TRICARE Prime to go to a military hospital or clinic, or to get a referral for urgent care from the MHS Nurse Advice Line, reachable at 800-874-2273, option 1. For active-duty members specifically, TRICARE says that getting care without the required referral means paying out of pocket; other Prime enrollees who see a specialist without a referral are using the point-of-service option, with higher out-of-pocket costs rather than the full bill. Emergency care is the exception: it does not need a referral or pre-authorization first, and in an emergency you should call 911 or go to the nearest emergency room.

For active-duty members assigned to Fort Bragg, the military clinic is typically the starting point for routine and specialty care. Emergencies are the exception: go to the nearest emergency room or call 911, with no referral needed first. Referrals from the military clinic follow the standard process: Womack gets first opportunity for specialty care, with civilian network providers as the secondary option if Womack cannot meet the need.

Not all care is subject to the Right of First Refusal. For TRICARE Prime beneficiaries other than active-duty service members, TRICARE lists outpatient mental health care visits among the services you can get from a network provider in your region without a referral from your primary care manager, so those visits can be scheduled directly. That is scoped to outpatient visits from a network provider in your own region, and other mental health services can still need pre-authorization, so it is worth checking before you book anything more involved. Active-duty service members are the exception: they need a referral and pre-authorization for nonemergency mental health care in the TRICARE network, consistent with their referral rules above. If you or someone you know is in crisis, call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24/7; veterans and service members can press 1 after dialing (or text 838255) to reach the Veterans Crisis Line. In a mental health emergency, call 911 or go to the nearest emergency room; no referral or pre-authorization is needed.

Emergency care is handled separately, and TRICARE covers it without a prior referral or pre-authorization. If you reasonably believe you have an emergency, call 911 or go to the nearest emergency room. TRICARE is explicit that urgent care clinics are not emergency rooms, so a walk-in clinic is the wrong destination for an emergency. Afterward, TRICARE Prime enrollees should contact their primary care manager within 24 hours or the next business day. TRICARE also says to follow up with that primary care manager for a referral for all specialty care, to avoid point-of-service fees. If an admission follows a psychiatric emergency, TRICARE says it should be reported to the regional contractor within 24 hours of admission, or the next business day after admission. TRICARE sets a separate outer limit on the same report: it must be made within 72 hours of the admission.

For non-emergency specialty care, plan on the referral process and allow time for the Right of First Refusal review before you expect an appointment.