TRICARE covers hospitalization services, including general nursing; hospital, physician, and surgical services; meals (including special diets); drugs and medications; operating and recovery room care;
anesthesia; laboratory tests; X-rays and other radiology services; medical supplies and appliances; and blood and blood products. Semiprivate rooms and special care units may be covered if medically necessary.
Surgical procedures designated by TRICARE as “inpatient only” may only be covered when performed in an inpatient setting.
All non-urgent admissions require prior authorization. In all emergency situations, the TRICARE Prime beneficiary must notify his or her Primary Care Manager (PCM) or Humana Military of any emergency inpatient admission within 24 hours or the next business day so ongoing care can be coordinated.
Requests for admissions authorizations may be entered through Provider Self Service
or faxed to Humana Military at 1-877-548-1547.
Skilled Nursing Facility Care
All admissions or transfers to a SNF require prior authorization. Skilled nursing care is provided at a SNF rather than in a nursing home or a patient’s home. TRICARE only covers care at Medicarecertified, TRICARE-participating SNFs in semiprivate rooms. Using a network facility decreases the cost to the beneficiary.
TRICARE covers skilled nursing services; meals (including special diets); physical, occupational, and speech therapy; drugs furnished by the facility; and necessary medical supplies, equipment, and appliances. Custodial care is not covered.
TRICARE only covers SNF admissions for patients with qualifying medical conditions treated in hospitals for at least three consecutive days (not including day of discharge). SNF admission may be covered as long as the patient is admitted within 30 days of his or her discharge from the hospital (with some exceptions for medical reasons).
For more information about SNF care, refer to the TRICARE Policy Manual
, Chapter 2, Section 4.1 and the TRICARE Reimbursement Manual, Chapter 8.
Bariatric surgery for morbid obesity must be prior-authorized and is covered for TRICARE beneficiaries who meet the criteria established by TRICARE. Only one bariatric surgery per lifetime is covered. In certain medically necessary circumstances, TRICARE will also cover bariatric-revision surgery.
TRICARE does not cover:
- Non-surgical treatment of obesity or morbid obesity (commercial diet programs, weight-loss supplements)
- Redundant skin surgery when performed solely for the purpose of improving appearance
- Biliopancreatic bypass, gastric bubble or balloon, gastric wrapping/open banding, or sleeve gastrectomy for the treatment of morbid obesity
- Devices used for bariatric surgery not approved by the U.S. Food and Drug Administration
Referring beneficiaries to Bariatric Surgery Centers of Excellence may reduce the risk of postoperative complications and early death after surgery. Surgeons and facilities with higher volumes of bariatric surgery have lower rates of complications. Approved facilities are certified by the American College of Surgeons as Level 1 Bariatric Surgery Centers or certified by the American Society for Bariatric Surgery as Bariatric Surgery Centers of Excellence. These facilities are listed at the CMS web site
. Providers should consider referring bariatric surgery candidates to Bariatric Surgery Centers of Excellence.
For more information on surgery for morbid obesity and the criteria, refer to the TRICARE Policy Manual
, Chapter 4, Section 13.2.
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