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 Government Designated Authority
(GDA), 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 United States (US) and US territories must be preauthorized
for TRICARE dual eligible beneficiaries. The TRICARE Medicare Eligible Program
(TMEP) 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. 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 7.1.
1.12 Each
TRICARE contractor may require additional care authorizations not
identified in this section. Such authorization requirements may
differ between geographic areas of responsibility. Beneficiaries
and providers are responsible for contacting their contractor for
a listing of additional authorization requirements in their geographic area.
1.13 The contractor
shall perform medically necessary reviews on a retrospective basis
when it determines a review is needed (to act as a secondary payor)
when a beneficiary has “other insurance” that provides primary coverage.
The preauthorization requirements in
paragraph 1.12. will not apply.
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.
1.14 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
EXCEPTION
The contractor shall obtain
the necessary information and perform a retrospective review when
TRICARE is primary payer for these services and preauthorization
was not obtained. 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.