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Provider Handbook
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Centers of Excellence for Bariatric Surgery
Prior Authorization for Active Duty Service Members
Tips for Submitting Authorizations |
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Centers of Excellence for Bariatric Surgery |
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Referring beneficiaries to Centers of Excellence (COE) for bariatric surgery 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.
In May 2006, the Centers for Medicare and Medicaid Services (CMS) implemented a Medicare National Coverage Decision that allows coverage for bariatric surgery only in approved facilities.
These facilities are certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center or certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence. These facilities are listed at the Centers for Medicare and Medicaid Services web site.
Humana Military has worked to bring these centers into the TRICARE South network. Please carefully consider referring candidates for this surgery to certified facilities. For TRICARE beneficiaries in the South Region, bariatric surgery requires prior authorization by Humana Military.
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Prior Authorization for Active Duty Service Members |
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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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Tips for Submitting Authorizations |
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For inpatient or outpatient prior authorizations, avoid waiting on the phone by submitting the request online. You may also fax the request, including clinical information, or call the IVR at Humana Military’s TRICARE Service Line: 1-800-444-5445. Make sure you have the following information:
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- Sponsor identification (ID), Social Security number, address
- Patient name, date of birth, relationship to sponsor
- Admitting hospital, date, time, physician tax ID, name and mailing address
- Clinical conditions for surgery, including CPT codes
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You may check the status of your prior authorization request online or by calling the Humana Military TRICARE Service Line at 1-800-444-5445. Most requests for authorization can be completed while you are on the phone or within 24 hours of receipt of all required information. Authorizations are valid only for care that begins within 30 days of receiving authorization. Providers may evaluate, stabilize, and treat patients for whom a full admission is not clear by using the 23-hour observation status. If after 23 hours the patient must continue as an inpatient, Humana Military must be notified. |
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