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Adjunctive vs. Non-adjunctive Dental Care: What's the Difference?  (Article 3)
The TRICARE health care benefit covers only adjunctive dental care. Adjunctive dental care is that dental care which is medically necessary in the treatment of an otherwise covered medical (not dental) condition; is an integral part of the treatment of such medical condition; or is required in preparation for, or as the result of, dental trauma that may be or is caused by medically necessary treatment of an injury or disease.

The TRICARE health care benefit does not cover non-adjunctive dental care, which refers to any routine, preventive, restorative, prosthodontic, periodontic or emergency dental care that is not related to a medical condition. TRICARE beneficiaries receive these dental services through military dental treatment facilities and through one of two TRICARE dental programs.

All adjunctive dental care requires prior authorization. Prior authorization will determine if a beneficiary’s condition is adjunctive or nonadjunctive dental care. The prior authorization requirement is waived only when essential adjunctive dental care involves a medical emergency, such as facial injuries resulting from a car accident.

Hospital services and supplies will be covered for a patient who requires a hospital setting for non-covered, nonadjunctive dental care when medically necessary to safeguard the life of the patient from the effects of dentistry on an underlying non-dental organic condition. Professional services related to the non-covered dental care are not covered; professional services related to the medical condition (excluding the dentist and anesthesiologist) are covered.

The following are some examples of adjunctive dental procedures that TRICARE covers:
  • Removal of teeth and tooth fragments to treat and repair facial trauma resulting from an accidental injury.
  • Total or complete ankyloglossia (tongue-tie) to alleviate difficulty swallowing or speaking. (Partial ankyloglossia is not covered.)
  • Dental or orthodontic care that is directly related to the medical and surgical correction of a severe congenital anomaly.
  • Dental care in preparation for, or as a result of, in-line radiation therapy for oral or facial cancer.
For a more detailed list of adjunctive dental procedures that TRICARE covers, access Chapter 8, section 13.1 of the TRICARE Policy Manual.

  Questions South Region Providers Are Asking (Article 4) 
  The consolidation of the new TRICARE South Region— which now includes Tennessee, except for the Ft. Campbell area; South Carolina; Georgia; Florida; Alabama; Mississippi; Arkansas; Oklahoma; and Texas, except the far western El Paso area—has been completed for four months. Former TRICARE Regions 3 and 4 transitioned on Aug. 1, 2004, while former Region 6 completed the transition on Nov. 1.

Here are the top 10 questions TRICARE providers have been asking since joining the South Region.
  When is a referral needed?
To receive full TRICARE Prime benefits, beneficiaries must contact their primary care manager (PCM) for a referral before receiving any type of nonemergency treatment outside of the PCM’s office. If you are a PCM, you will initiate all referrals except for behavioral health care. Referrals must be authorized by calling a Humana Military Health Care Finder (HCF) at 1-800-444-5445. Referrals also can be processed online by going to Provider Resources.

When is a prior authorization required?
All inpatient hospital admissions and certain procedures require prior authorization. Refer to the chart in your TRICARE Provider Handbook for a listing of these procedures along with corresponding CPT codes.

How do I request a prior authorization?
Prior authorization requests may be made online, by phone or via fax. See the “Tips for Submitting Authorizations” section of the TRICARE Provider Handbook.

Does TRICARE provide case management?
Yes, Humana Military nurses provide case management services for beneficiaries with complex health needs. Contact your local TRICARE Service Center if you have a TRICARE patient who may need case management. Refer to the TRICARE Provider Handbook for a list of conditions that call for referral to case management for evaluation.

Does TRICARE have contracted laboratories?
Yes, the TRICARE network of contracted laboratory service providers includes Quest Diagnostics® and LabCorp® of America.

How does TRICARE define an emergency?
TRICARE defines a true emergency as the sudden onset or worsening of a condition that is threatening to life, limb or sight. An emergency condition requires immediate medical attention either to treat the condition or relieve suffering from painful symptoms. Any delay in treatment would mean risk of permanent damage to the patient’s health. If a prudent layperson would reasonably believe that a true emergency as described is present, TRICARE will cover the emergency department care.

Does an inpatient admission after emergency care require an authorization?
Yes, hospitals must obtain authorization by calling a Humana Military HCF at 1-800-444-5445 within 24 hours of an emergency hospital admission. TRICARE Prime members must also contact their PCM for approval in the same time frame or the admission may be covered under the point-of-service option, which includes a deductible and cost-shares.

Does TRICARE allow for outpatient observation?
Physicians may evaluate, stabilize and treat patients for whom a full admission is not clear by using the 23-hour outpatient observation status. While outpatient observation stays generally should not exceed 23 hours, up to 48 hours of outpatient observation services may be authorized by Humana Military when medical necessity is clearly demonstrated. Observation stays of more than 48 hours will be processed as inpatient stays and require prior authorization.

Where do I file my claims?
The claims processor for the TRICARE South Region is PGBA, LLC (PGBA). PGBA can be contacted at 1-800-403-3950 or questions can be mailed to: PGBA South Region Claims Department, P.O. Box 7031, Camden, SC 29020-7031. Network providers must submit claims electronically. For more information on electronic claims submission c
all your TRICARE provider relations representative.

How can I check on the status of my claims?
Providers can check the status of their claims online if they register for Online Provider Services
. Providers may also call the PGBA automated voice response system at 1-800-403-3950.

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