For a sprained wrist or a nasty viral infection, you'll need to head to the doctor. Chances are, the problem can be fielded easily by a Primary Care Manager (PCM) physician. However, when a medical issue requires more extensive or specific care, patients often have to enlist the services of a specialty clinic - both inside and outside of - the Madigan Healthcare System.

The first step to any referral starts with an initial visit to the PCM, who will assess the patient's situation, concerns and needs. The PCM can then make an educated decision as to whether the patient will receive the best care through primary care or if a referral to a specialist is needed. For example, many diabetics receive their care from a PCM rather than the Endocrinology Clinic, but each case is assessed individually.   

When services or procedures are required that cannot be provided by the PCM or a clinic within Madigan, a referral is always necessary. Except for emergencies, active duty Servicemembers must have a referral for all care obtained outside of Madigan. Likewise, TRICARE Prime beneficiaries require a referral for most non-PCM care.

Two to three days after the referral has been entered by a PCM, patients are asked to call the TRICARE appointment scheduling line (800) 404-4506) to make an appointment with that the specialty clinic. For more information about the progress of a referral within Madigan, beneficiaries can call the Madigan Referral Coordination Office at (253) 968-2903.

So when does a referral move outside of Madigan's walls? The specialty clinic always has the first right of refusal, meaning that it needs to first verify if it has room in the schedule to accommodate a new patient. If it does, TRICARE beneficiaries must wait for the first appointment within the Madigan clinic. If the Madigan clinic cannot accommodate new patients, it will then push the referral outside to civilian providers in the TRICARE network.

At that point, beneficiaries can gather the necessary information for their referral a number of ways. They can log in through the TriWest portal (www.triwest.com/en/beneficiary/registration) to view authorizations and print referrals at home. They can also call TriWest at (888) 874-9378 and speak with a representative who can provide the authorization number for the referral (which the civilian doctor will require). Regardless of any earlier steps, a printed copy of the referral authorization will be mailed to the patient within a five-day period.

Once the authorization is in the system, appointments with the civilian provider can be scheduled. If a beneficiary receives specialty care without an approved referral, TRICARE may only cover 50 percent of the services, if any.

Once a referral is on record with TriWest, patients have the option of requesting a different provider, as long as he or she is in-network and classified under the same specialty stipulated as the original referral. To search for in-network civilian providers, utilize the search engine www.triwest.com/OnlineProviderDirectory.

Lastly, remember that referrals are time sensitive and issued with an expiration date - typically in three or six month intervals. Continuous care with a specialist outside of Madigan will require updated referrals in order for services to continue to be covered in full.