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.
1.4 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.
1.9 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.
1.11 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.
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.