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Specialist-to-Specialist Referrals for the Same Episode of Care
Prior Authorizations

 
Specialist-to-Specialist Referrals for the Same Episode of Care
Some referrals may be authorized from one specialty care provider to another, bypassing the need to get another PCM referral.
  • It will apply only when a valid “Evaluate and Treat” referral from the PCM has previously been authorized for the same episode of care.
  • It will not apply to active duty service members (ADSMs).
  • The MTF “Right of First Refusal” (ROFR) policy will remain in effect.
  • The referring specialist, the receiving specialist, and the primary care manager will be notified of all such referrals by autofax, keeping the entire care team aware of these clinical contacts.
  • Not all specialist-to-specialist referrals will be authorized.
To ensure timely receipt of AutoFax transmissions it will be necessary to leave fax machines on after hours, including weekends. Please report any fax number changes to your provider relations representative. Please program your office/referral fax number into your fax machine to ensure that it appears on your referral request.


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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 (see Figure 7.1). 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 by one of three ways:
 
  1. Submit requests online via the Humana Military Web site.
     
  2. Fax a completed PRAF form to 1-877-548-1547.
     
  3. Call the IVR at Humana Military’s TRICARE Service Line at 1-800-444-5445.

 
Prior Authorization List for the South Region (Effective 4/1/2006)

Fig. 7.1
Procedures and Services   Inpatient Hospital Stays
Adjunctive dental   Admissions or transfers to SNF, Rehab, LTAC
Home health services including home infusion   Notification of acute care admission by the next working day
Extended Care Health Option (ECHO) services   Discharge notification
Hospice   Concurrent reviews upon request by Humana Military
Speech therapy   Durable Medical Equipment (DME)
Transplants (solid organ and stem cell, nor corneal transplant)   Power vehicle or wheelchair
Hysterectomy (abdominal, laparoscopic, vaginal)   Any DME with miscellaneous code if purchase price is greater than $500
Termination of pregnancy   Continuous passive motion (CPM) device
Reduction Mammoplasty   Patient lift
Uvulopalatopharyngoplasty (UPPP)   Bone growth stimulator
Blepharoplasty   Behavioral Health
Bariatric surgery   Psychoanalysis
    Psychological and neuropsychological testing
    Inpatient hospital
    Electroconvulsive therapy (ECT)
    Outpatient crisis intervention
The services listed in Figure 7.1 require prior authorization for all TRICARE beneficiaries except for ADSMs. For information about obtaining prior authorization for ADSMs, see the section later in this chapter titled, “Prior Authorization for Active Duty Service Members.”


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Last Update: July, 2007