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.