Prior Authorizations or Prospective Review
Certain requested services, procedures, or admissions require prior authorization. The primary focus of prospective review is to ensure services requested are medically necessary and provided in the appropriate setting. Prospective review (preauthorization) is the process by which specified services are reviewed for medical necessity prior to the services being provided.
Prior authorizations are based on medical necessity and are not a guarantee of payment. When a TRICARE provider fails to obtain prior authorization, or exceeds the scope of an approved referral/authorization, he or she may incur penalties.
Figure 6.2 below lists procedures and services that require prior authorization. ADSMs require prior authorization (except for emergencies) for all inpatient and outpatient services from civilian network or non-network providers. This is to ensure that ADSMs continue to meet fitness-for-duty requirements as a result of outpatient visits such as pregnancy (maternity) care, physical therapy, behavioral health care services, and family counseling.
First-level reviewers may issue denial determinations based on coverage limitations contained in 32 Code of Federal Regulations (CFR) 199, the TRICARE Policy Manual, and other TRICARE guidance (these are considered factual determinations) or refer the case to second-level review. Physicians who did not participate in the first-level review of the care under consideration conduct second-level reviews.
Concurrent review is the review of continued inpatient stay to determine medical necessity, quality of care, and appropriateness of the level of care being provided. Concurrent review ensures appropriate, efficient, and effective utilization of medical resources.
Retrospective review Retrospective review is conducted when a certain procedure or service requires a medical necessity review but was not previously authorized.
Case Case management services are provided by Humana Military nurses for TRICARE beneficiaries with complex health needs. The following conditions warrant mandatory referral to case management:
- Transplant evaluation or procedure (solid organ or bone marrow/peripheral stem cell)
- Ventilator dependence
- Acute inpatient rehabilitation (not skilled facility with therapy only)
- Traumatic brain injury, spinal cord injury, stroke, new blindness
- New quadriplegia or paraplegia
- Premature infant: ventilator-dependent more than 24 hours and/or weight less than 1,500 grams
- Planned long-term acute care admission
- Catastrophic illness or injury, amputation, multiple trauma
- Pregnancy with significant identified risks
- Hourly nursing care more than four hours per day
- Burn injury requiring a burn unit
- Unplanned admissions to acute hospital three times or more within 90 days with the same diagnosis
- Chronic condition resulting in high resource consumption (e.g., hemophilia, Gaucher’s disease)
- ECHO requests
- Transfer to an MTF or network facility
This list is not all-inclusive and is subject to change. Any beneficiary with a complex case who may benefit from case management is eligible for an evaluation and should be referred to Humana Military.