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The Department of Defense requires civilian care be medically necessary and compliant with TRICARE benefits. Humana Military strives to meet this requirement without creating barriers to care. Prior authorization and prepayment review are two ways of doing so.
Humana Military requires prior authorization for services with known variation in utilization, limitations in coverage, or both. This enables providers and beneficiaries to confirm the service will be viewed as medically necessary and a covered benefit before it is provided.
Effective April 1, 2006, Humana Military began reducing the number of procedures that require prior authorization. The following services no longer require prior authorization: septoplasty, orthotics, prosthetics, electric hospital bed, CPAP, apnea monitor, and pneumatic compressor.
A table listing services still requiring prior authorization is shown below.
The best way to determine if proposed care or services for TRICARE beneficiary requires prior authorization is to utilize the code look up function online. Code look up will indicate if authorization is required for the specific code you enter. If authorization is required, you can request the authorization online. Often you will get an authorization in minutes.
Humana Military performs prepayment review if a claim for a service is received that requires prior authorization and authorization was not obtained.
This review is performed after the service is rendered but before the claim is processed. TRICARE does not deny the claim simply because prior authorization was not received.
When the service is approved, the claim is paid with a penalty of at least 10 percent for failure to obtain required prior authorization. Provider agreements specify the penalty amount if greater than 10 percent.
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