TRICARE Manuals - Display Chap 7 Sect 2 (Change 95, Aug 24, 2021)

Medical Management (MM), Utilization Management (UM), And Quality Management (QM)

Chapter 7

Section 2

Preauthorizations

Revision: C-65, April 29, 2020

1.0 General

1.1 A preauthorization is a comprehensive review process for certain services to determine that requested treatment may be covered as medically necessary, delivered at the appropriate setting, and is a TRICARE benefit before services are rendered to the beneficiary.

1.2 Preauthorization review shall be performed for all care and procedures listed below except as provided in paragraph 2.0. The contractor may propose additional authorization reviews. (See Section 1 for additional guidance.) The admissions/procedures are subject to change over time based upon the Government’s assessment of the efficacy of the review. The changes will include adding and/or removing admissions/procedures. When the beneficiary has other insurance that provides primary coverage, exception to the preauthorization requirements shall apply as provided in the TRICARE Policy Manual (TPM), Chapter 1, Section 6.1, paragraph 1.12. When the contractor is acting as a secondary payor any medically necessary reviews shall be performed on a retrospective basis.

The Following Inpatient Admissions shall Be Preauthorized:
Adjunctive Dental
Mental Health and Substance Use Disorder (SUD) - Non-emergency inpatient mental health services (acute hospitalization psychiatric care, Residential Treatment Center (RTC) care, and SUD inpatient/residential detoxification and rehabilitation) require preauthorization. In the event that inpatient mental health services were not preauthorized, the contractor shall obtain the necessary information and complete a retrospective review. Penalties for failing to obtain preauthorization apply (see 32 CFR 199.15).
Skilled Nursing Facility (SNF) care for dual eligible beneficiaries Note: Effective for dates of service June 1, 2010, 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 shall 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.
Organ and Stem Cell Transplants

The Following Outpatient Services shall Be Preauthorized:
Adjunctive Dental
Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), and Psychoanalysis (see TPM, Chapter 7, Section 3.8)
Spravato™ (esketamine) nasal spray shall be preauthorized under the medical benefit (see TPM, Chapter 7, Section 3.8)

The Following Services Will Be Preauthorized In Any Setting:
Extended Care Health Option (ECHO) Services and the Autism Care Demonstration
Home Health Care
Hospice
Provisional Coverage for Emerging Services and Supplies, if required (see the TPM, Chapter 13, Section 1.1.)
Low Protein Modified Foods (LPMF) for the treatment of Inborn Errors of Metabolism (IEM) (see the TPM, Chapter 8, Section 7.2)
Dental Anesthesia and Institutional Benefits
Electroconvulsive Therapy (ECT)
Transcranial Magnetic Stimulation (TMS)
Psychoanalysis

2.0 TRICARE Prime Preauthorization

2.1 Primary Care Manager (PCM) Referral To Inpatient Care

Preauthorization is only required with respect to a PCM’s referral for:

• Inpatient hospitalization;

• Inpatient care at a Skilled Nursing Facility (SNF);

• Inpatient care at a rehabilitation facility; and

• Inpatient care at a Residential Treatment Facility (RTF).

2.2 In the case of care for which preauthorization is not required under paragraph 2.1, the contractor may be authorized to offer a voluntary preauthorization program to enable beneficiaries and providers to confirm covered benefit status and/or medical necessity or to understand the criteria that will be used by the contractor to adjudicate the claim associated with the proposed care. A network provider, however, may not be required to use such a program with respect to a referral.

3.0 Outpatient Mental Health And SUD

Outpatient mental health care (to include Partial Hospitalization Programs (PHPs), Intensive Outpatient Programs (IOPs), Opioid Treatment Programs (OTPs), Office-Based Opioid Treatment (OBOT), and office -based outpatient treatment) does not require preauthorization. TRICARE no longer requires continued authorization after the eighth outpatient mental health visit each fiscal year. PCM referral is not required for outpatient, office-based mental health and SUD visits to an authorized TRICARE network provider; however, all other outpatient mental health and SUD services require a referral from the PCM or other network TRICARE authorized institutional or individual professional mental health or SUD provider as authorized in the TPM, Chapter 7, Section 3.5, paragraph 4.0 and TPM, Chapter 7, Section 3.8, paragraph 6.0. The contractor shall steer all beneficiaries who contact them to the Military Treatment Facility/Enhanced Multi-Service Market (MTF/eMSM) or appropriate network provider. Additionally, the contractor shall expound upon the benefits of using the MTF/eMSM and network providers during all appropriate beneficiary and provider briefings. See Chapter 16, Sections 2 and 6 for referral requirements under the TRICARE Prime Remote (TPR) program.

Note: Active Duty Service Members (ADSMs) require preauthorization before receiving mental health and SUD services. The contractor shall comply with the provisions of Chapters 16 and 17 when processing requests for active duty personnel. See Chapter 16, Sections 2 and 6 for referral requirements under the TPR program.

4.0 Effective And Expiration Dates

The preauthorization shall have an effective date and an expiration date.

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