Prior Authorizations for Care
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A prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care. Prior authorizations must be obtained before services are rendered or within 24 hours or on the business day following an emergency admission.
Your PCM or specialty care provider will request prior authorization from Humana Military, if necessary. If the service is authorized, Humana Military will give your PCM or specialty care provider an authorization number and specific instructions. For example, prior authorizations for medical or surgical services have a begin date and end date. Prior authorizations for behavioral health care services specify a number of visits as well as a begin date and end date. You must receive care under the authorization before it expires. If not, you will need to get another referral and authorization from your PCM or specialty care provider.
Services Requiring Prior Authorization
ADSMs require prior authorization for all inpatient and outpatient specialty services. An additional fitness-for-duty review is required for maternity care, physical therapy, behavioral health care services, family counseling, and smoking cessation programs.
For all other TRICARE Prime enrollees, the following services require prior authorization:
Adjunctive dental services Extended Care Health Option services Home health care services Hospice care Nonemergency inpatient admissions for substance use disorders or behavioral health care Outpatient behavioral health care beyond the eighth visit per FY (October 1 - September 30) - Transplants—all solid organ and stem cell
This list is not intended to be all-inclusive.
Visit Humana Military’s Prior Authorization list ( updated April 1, 2009) or call 1-800-444-5445 to learn about their requirements, as they may change periodically. |
