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Prior Authorizations

     
An authorization is issued for requested services, procedures, or admissions that require medical necessity review prior to services being rendered. Prior authorizations are based on medical necessity and are not a guarantee of payment. Provider penalties may be applied when a TRICARE provider fails to obtain prior authorization or exceeds the scope of an approved referral/authorization.

Prior authorizations may be requested in various ways.  The fastest, most efficient way is to submit requests online via the Humana Military Web site.

For more information, refer to the Provider Handbook.

Prior Authorization List for the South Region

Procedures and Services Inpatient Hospital Stays
Adjunctive dental Admissions or transfers to skilled nursing facility, rehabilitation, long-term acute care
Advanced life support air ambulance in conjunction with stem cell transplantation Discharge notifications
Bariatric surgery Notification of acute care admission by the next working day
Educational interventions under the Enhanced Access to Autism Services Demonstration Behavioral Health
Extended Care Health Option (ECHO) services All nonemergency inpatient admissions for behavioral health care or substance use disorder
Home health services, including home infusion Partial hospitalization programs (psychiatric and substance use disorder)
Hospice Psychoanalysis
Phase II and Phase III cancer clinical trials Residential treatment center programs
Transplants (solid organ and stem cell, not corneal transplant) Outpatient behavioral health visits exceeding the initial eight visits each fiscal year (October 1 to September 30)

Prior Authorization for Active Duty Service Members

ADSMs require prior authorization (unless it is an emergency) 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 services, family counseling, and smoking cessation programs.

Providers who do not obtain a prior authorization when one is required, or exceed the scope of an approved prior authorization, risk not being paid or being charged a penalty.

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Last Update: April 21, 2014