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TRICARE Policy Manual 6010.60-M, April 1, 2015
Administration
Chapter 1
Section 6.1
Special Authorization Requirements
Issue Date:  August 4, 1988
Revision:  C-61, April 17, 2020
1.0  Policy
Unless otherwise specifically excepted, the adjudication of the following types of care is subject to the following authorization requirements:
1.1  Adjunctive dental care must be preauthorized.
1.2  Dental anesthesia and institutional benefit must be preauthorized. See Chapter 8, Section 13.2, paragraph 2.5.
1.3  Extended Care Health Option (ECHO) benefits must be authorized in accordance with Chapter 9, Section 4.1.
1.4  Effective October 1, 1991, preadmission and continued stay authorization is required before nonemergency inpatient mental health services may be cost-shared (includes Residential Treatment Center (RTC) care and inpatient/residential Substance Use Disorder (SUD) detoxification and rehabilitation).
1.5  Effective November 18, 1991, psychoanalysis must be preauthorized.
1.6  The Director, Defense Health Agency (DHA), or designee, may require preauthorization of admission to nonemergency inpatient facilities.
1.7  Organ and stem cell transplants are required to be preauthorized. For organ and stem cell transplants, the preauthorization shall remain in effect as long as the beneficiary continues to meet the specific transplant criteria set forth in this TRICARE Policy Manual (TPM), or until the approved transplant occurs.
1.8  Infusion therapy delivered in the home must be preauthorized in accordance with Chapter 8, Section 20.1.
1.9  Effective for dates of service June 1, 2010, Skilled Nursing Facility (SNF) care received in the U.S. and U.S. territories must be preauthorized for TRICARE dual eligible beneficiaries. The TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) contractor will preauthorize SNF care beginning on day 101, when TRICARE becomes primary payer. For those beneficiaries inpatient on the effective date, a preauthorization will be required August 1, 2010. See the TRICARE Operations Manual (TOM), Chapter 7, Section 2 and the TRICARE Reimbursement Manual (TRM), Chapter 8, Section 1.
1.10  Provisional coverage for emerging service and supplies shall be preauthorized in accordance with Chapter 13, Section 1.1 and TOM, Chapter 7, Section 2.
1.11  Medically necessary low protein modified foods for the treatment of inborn errors of metabolism shall be preauthorized in accordance with Chapter 8, Section 7.2.
1.12  Each TRICARE contractor may require additional care authorizations not identified in this section. Such authorization requirements may differ between regions. Beneficiaries and providers are responsible for contacting their contractor for a listing of additional regional authorization requirements.
Note:  When a beneficiary has “other insurance” that provides primary coverage, preauthorization requirements in paragraph 1.12. will not apply. Any medically necessary reviews the contractor believes are necessary, to act as a secondary payor, shall be performed on a retrospective basis. The conditions for applying this exception are:
•  The Other Health Insurance (OHI) must be primary under the provisions of the TRM, Chapter 4, Section 1.
•  Documentation that the OHI processed the claim and of the exact amount paid must be submitted with the TRICARE claim.
1.13  Provider payments are reduced for the failure to comply with the preauthorization requirements for certain types of care. See the TRM, Chapter 1, Section 28.
1.14  Effective March 5, 2019, Spravato™ (esketamine) nasal spray shall require preauthorization under the medical benefit in accordance with Chapter 7, Section 3.8 and TOM, Chapter 7, Section 2.
2.0  EXCEPTIONS
2.1  For dual eligible beneficiaries, these requirements apply when TRICARE is primary payer. As secondary payer, TRICARE will rely on and not replicate Medicare’s determination of medical necessity and appropriateness in all circumstances where Medicare is primary payer. In the event that TRICARE is primary payer for these services and preauthorization was not obtained, the contractor will obtain the necessary information and perform a retrospective review.
2.2  The requirement that a TRICARE Prime enrollee obtain a referral/authorization from their Primary Care Manager (PCM) to receive the H1N1 immunization from a non-network, TRICARE-authorized provider has been temporarily waived from October 1, 2009 to May 1, 2010. During this period, Prime enrollees may obtain the H1N1 immunization from a non-network TRICARE-authorized provider without prior authorization or PCM referral. Point Of Service (POS) cost-shares normally associated with non-referred care obtained by Prime enrollees from non-network providers without appropriate authorization will not apply during this period.
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