Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDHA Specialty Travel Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedDHAPolicy 6010.64-M

    Reimbursement of Travel Expenses for Specialty Care

    Customize your policy alerts

    Sign up for DHA Policy 6010.64-M alerts

    Get alerted when Policy 6010.64-M changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs reimbursement of reasonable travel expenses for eligible TRICARE Prime and TRICARE Prime Remote enrollees and certain retirees who must travel for medically necessary, non-emergent specialty care. It also directs contractors on handling inquiries and eligibility involving active-duty family members, NOAA or Public Health Service sponsors, and retirees with combat-related disabilities.

    Policy Summary
    PayerDHA
    PolicyReimbursement of Travel Expenses for Specialty Care
    Policy CodePolicy 6010.64-M
    Change TypeModified
    Effective DateDec 18, 2025
    Next Review DateN/A
    Key ActionConfirm that the enrollee has a qualifying referral, meets the applicable distance rule, and has no suitable specialist available within the threshold.
    SourceLink
    POLICY UPDATE CHANGES

    Eligibility provisions were added for non-active-duty TRICARE Prime and TRICARE Prime Remote enrollees who are family members of active-duty armed forces members and require specialty care beyond the applicable mileage threshold.

    Prime Travel Benefit entitlement was aligned with the enrollee's sponsor category and limited to referrals for which no other suitable specialist is available within 75 or 100 miles one way of the primary care manager's office.

    Prime Travel Benefit eligibility in Alaska and Hawaii was limited to active-duty family members who do not reside on assignment with their sponsors.

    For TRICARE Prime Remote active-duty family members with an unassigned primary care manager, the mileage threshold was changed from 100 miles to 75 miles and is measured from the referring provider's office to the specialty provider.

    Contractor inquiries about travel reimbursement for non-TRICARE Prime retirees with combat-related disabilities must be referred to the Defense Health Agency Prime Travel Benefit Branch.

    Eligibility for certain active-duty family members is aligned to sponsor category and the applicable 75-mile or 100-mile distance threshold.

    The distance measurement for TRICARE Prime Remote active-duty family members with an unassigned PCM is determined from the referring provider's office to the specialty provider.

    Travel reimbursement inquiries for non-Prime retirees with combat-related disabilities and United States Coast Guard beneficiaries are directed to the DHA Prime Travel Benefit Branch or its travel representative.

    Qualifying enrollees must submit a trip reimbursement claim within one year after the last date of travel.

    Qualifying United States Coast Guard beneficiaries may receive reimbursement for specialty care travel of less than 100 miles when they reside on an eligible island without public access roads to the mainland.

    75 or 100 milesApplicable one-way specialty-care distance threshold
    1 yearDeadline to submit a qualifying trip reimbursement claim
    Alaska and HawaiiLocations with a special active-duty family-member eligibility limitation
    Sponsor categoryFactor determining applicable travel-benefit entitlement
    1 attendantMaximum medically necessary attendant for qualifying Coast Guard travel

    Prime Travel Benefit Eligibility

    Prime Travel Benefit Eligibility

    The Prime Travel Benefit (PTB) may reimburse reasonable travel expenses when all applicable eligibility and referral requirements are met.

    ALL of the following

    • The beneficiary is enrolled in TRICARE Prime or TRICARE Prime Remote (TPR).
    • The beneficiary requires non-emergent, medically necessary specialty care.
    • The beneficiary is referred for specialty care by the applicable Primary Care Manager (PCM), or by the referring provider when a TRICARE Prime Remote Active Duty Family Member (TPRADFM) has an unassigned PCM.
    • The specialty referral meets the applicable distance and specialist-availability requirements.
    Policy Summary
    PayerDHA
    PolicyReimbursement of Travel Expenses for Specialty Care
    Policy CodePolicy 6010.64-M
    Change TypeModified
    Effective DateDec 18, 2025
    Next Review DateN/A
    Key ActionConfirm that the enrollee has a qualifying referral, meets the applicable distance rule, and has no suitable specialist available within the threshold.
    SourceLink
    On This Page
    Prime Travel Benefit EligibilityDistance and Claim ParametersOperational RequirementsDefined Terms

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    The reimbursement claim is submitted within one year of the last date of travel.

    Sponsor and Location Restrictions

    Eligibility is aligned to the enrollee’s sponsor category and location.

    ALL of the following

    • The enrollee is in a qualifying sponsor category, including a family member of an armed forces member on active duty, a retiree or family member of a retiree, or a family member of a National Oceanic and Atmospheric Administration (NOAA) or Public Health Service (PHS) member.

    • ONE of the following location conditions

      • For an Active Duty Family Member (ADFM) in Alaska or Hawaii, the ADFM does not reside on assignment with the active-duty sponsor.
      • The enrollee is not subject to the Alaska/Hawaii assignment restriction applicable to ADFMs.

    Combat-Related Disability Retiree Eligibility

    A non-TRICARE Prime retiree may qualify through the combat-related disability pathway.

    ALL of the following

    • The individual is a retiree with a combat-related disability determined by the member’s Branch of Service.
    • The retiree is not enrolled in TRICARE Prime.
    • A Primary Care Provider (PCP) refers the retiree for follow-on specialty care related to the specific disability listed in the Combat-Related Special Compensation (CRSC) letter.
    • The specialty care is more than 100 miles one way from the office where the PCP provides services to the retiree.> 100 miles one way
    • The Defense Health Agency (DHA) PTB Branch determines whether the specialty care meets the distance requirement.

    Prime and Prime Remote Specialty Travel Eligibility

    The applicable distance threshold and measurement points depend on the enrollee’s sponsor category and PCM assignment.

    ONE applicable pathway

    • TRICARE Prime or TPR enrollee with an assigned PCM

      • The referral is for non-emergent, medically necessary specialty care, and no suitable specialist—including a Market or Military Treatment Facility (MTF), network, or non-network specialist—is available within the applicable distance one way from the PCM’s office.> 75 or 100 miles one way
      • The applicable threshold is determined by the enrollee’s sponsor category.

    • TPRADFM with an unassigned PCM; active-duty armed forces sponsor

      • No suitable specialty provider is available within 75 miles one way.
      • Distance is measured from the referring provider’s office to the specialty provider.> 75 miles one way

    • TPRADFM with an unassigned PCM; NOAA or PHS sponsor

      • No suitable specialty provider is available within 100 miles one way.
      • Distance is measured from the referring provider’s office to the specialty provider.> 100 miles one way

    Retiree and USCG Specialty Travel Eligibility

    Separate eligibility pathways apply to qualifying retirees and United States Coast Guard (USCG) beneficiaries.

    ONE applicable pathway

    • Qualifying retiree pathway

      • The retiree meets the combat-related disability, non-TRICARE Prime enrollment, PCP referral, disability-specific follow-on care, and distance requirements.
      • The DHA PTB Branch determines whether the specialty care is more than 100 miles one way from the provider’s office.> 100 miles one way

    • USCG island beneficiary pathway

      • The beneficiary is a non-active-duty USCG beneficiary, meaning an active-duty dependent, who resides on an island within the continental United States (CONUS).
      • The island has no public access roads to the mainland.
      • The beneficiary is enrolled in TRICARE Prime or TPRADFM and is referred to specialty care by the PCM.
      • No other specialist, including a Market or MTF, network, or non-network specialist, is available on the island.
      • The specialty care is less than 100 miles one way; reimbursement may include travel for one medically necessary attendant.< 100 miles one way
      • Questions about USCG travel reimbursement are referred to the appropriate DHA PTB Branch travel representative.

    Distance and Claim Parameters

    Standard specialty-care travel distance
    DistanceMore than 100 miles one way
    Starting pointPrimary Care Manager's office
    DestinationNearest suitable specialist's office
    Alternative specialist availability threshold
    Availability requirementNo suitable specialist is available within the applicable distance
    Applicable thresholds75 or 100 miles one way
    Measurement pointPrimary Care Manager's office
    TPRADFM unassigned PCM threshold
    Distance75 miles
    Measurement routeFrom the referring provider's office to the specialty provider
    Applicable beneficiaryTRICARE Prime Remote active-duty family member with an unassigned Primary Care Manager
    NOAA/PHS unassigned PCM threshold
    Distance100 miles
    Measurement routeFrom the referring provider's office to the specialty provider
    Applicable beneficiaryTRICARE Prime Remote family member of a NOAA or Public Health Service member with an unassigned Primary Care Manager
    Combat-related disability retiree threshold
    DistanceMore than 100 miles one way
    Measurement pointWhere the Primary Care Provider provides services to the retiree
    Determining authorityDHA Prime Travel Benefit Branch
    Claim filing deadline
    DeadlineOne year from the last date of travel
    Applies toQualifying trip reimbursement claims
    Claim typeTravel reimbursement claim
    Armed forces active-duty family member distance threshold
    Distance75 miles one way
    Standard measurement pointPrimary Care Manager's office
    Unassigned PCM measurementFrom the referring provider's office to the specialty provider
    NOAA, PHS, and other generally applicable specialty referral distance threshold
    Distance100 miles one way
    Applicable categoriesNOAA, Public Health Service, and other generally applicable specialty referrals
    Unassigned PCM measurementFrom the referring provider's office to the specialty provider
    USCG island beneficiary distance condition
    Travel distanceLess than 100 miles one way
    Residence conditionBeneficiary resides on an island within the continental United States
    Access conditionNo public access roads to the mainland
    Claim submission deadline
    Submission periodWithin one year of the last date of travel
    Applies toQualifying travel reimbursement claims
    Trigger dateLast date of travel

    Operational Requirements

    Documentation Required

    Verify Prime Travel Benefit eligibility

    Confirm that the enrollee is a qualifying TRICARE Prime or TRICARE Prime Remote enrollee, the referral is for non-emergent, medically necessary specialty care, and no suitable specialist is available within the applicable one-way distance threshold.

    Billing Rule

    Apply category-specific mileage rules

    Apply the mileage threshold and measurement point that correspond to the enrollee’s sponsor category and primary care manager assignment status.

    • For applicable referrals, the threshold is 75 or 100 miles one way from the PCM’s office.
    • For a TPRADFM enrollee with an unassigned PCM, measure 75 miles from the referring provider’s office to the specialty provider.
    • For NOAA or PHS family members with an unassigned PCM, measure 100 miles from the referring provider’s office to the specialty provider.
    Billing Rule

    Meet claim submission deadline

    Submit qualifying trip reimbursement claims within one year after the last date of travel.

    Documentation Required

    Route retiree travel inquiries

    Refer inquiries about travel reimbursement for non-TRICARE Prime retirees with combat-related disabilities to the DHA Prime Travel Benefit Branch.

    Prior Authorization

    Refer qualifying Prime beneficiaries for specialty care travel reimbursement

    Refer eligible TRICARE Prime or TRICARE Prime Remote enrollees for non-emergent, medically necessary specialty care when the nearest suitable specialist is beyond the applicable distance threshold and no suitable specialist is available within that threshold.

    • Confirm the applicable sponsor category and distance threshold.
    • Document the specialty referral and specialist-availability determination.
    Documentation Required

    Handle combat-related disability retiree inquiries

    For a non-Prime retiree, route specialty care travel reimbursement inquiries to the DHA Prime Travel Benefit Branch. Eligibility requires a combat-related disability, a PCP referral, follow-on specialty care related to the disability identified in the CRSC letter, and travel of more than 100 miles one way from where the PCP provides services.

    Documentation Required

    Route travel reimbursement inquiries

    Refer United States Coast Guard beneficiary travel reimbursement inquiries to the appropriate DHA Prime Travel Benefit travel representative; route other travel questions according to the applicable Market/MTF or DHA branch direction.

    Documentation Required

    Document travel reimbursement eligibility

    Document the required PCM or PCP referral, confirm that no qualifying specialist is available within the applicable geographic limit, and ensure the trip reimbursement claim is submitted within one year after the last date of travel.

    • For Prime and Prime Remote referrals, apply the applicable 75- or 100-mile one-way threshold.
    • For combat-related disability retirees, verify that specialty care is more than 100 miles one way from the PCP’s service location.

    Defined Terms

    Prime Travel Benefit (PTB)
    BenefitTravel reimbursement for eligible TRICARE enrollees
    Covered travelQualifying specialty care beyond the applicable mileage threshold
    Expense standardReasonable travel expenses
    Active Duty Family Members (ADFMs)
    MeaningFamily members of armed forces members on active duty
    Common abbreviationADFMs
    Relevant benefit contextMay qualify for the Prime Travel Benefit when applicable referral and distance requirements are met
    Retiree with a combat-related disability
    BeneficiaryA retiree not enrolled in TRICARE Prime
    Disability determinationDisability determined by the member's Branch of Service
    Related careFollow-on specialty care related to the specific disability listed in the Combat-Related Special Compensation letter
    Prime Travel Benefit (PTB)
    BenefitTravel reimbursement for eligible beneficiaries
    PurposeTravel for medically necessary specialty care
    Distance conditionBeneficiary must travel beyond the applicable distance threshold
    TPRADFM
    EnrollmentTRICARE Prime Remote enrollee
    Family relationshipFamily member of an armed forces member on active duty
    AbbreviationTPRADFM
    Combat-related disability
    Nature of disabilityA retiree's combat-related disability
    DeterminationDetermined by the member's Branch of Service
    DocumentationIdentified in the retiree's Combat-Related Special Compensation letter
    Qualifying USCG island beneficiary
    BeneficiaryNon-active-duty United States Coast Guard beneficiary
    ResidenceResides on an island within the continental United States
    Access conditionIsland has no public access roads to the mainland