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Prior Authorizations
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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 Authorizations (updated April 1, 2009)
Procedures and Services
- Adjunctive Dental
- Home health services including home infusion
- Extended Care Health Option (ECHO) services
- Hospice
- Transplants (solid organ and stem cell, nor corneal transplant)
- Bariatric surgery
- Educational interventions under Enhanced Access to Autism Services Demonstration
- Advanced life support air ambulance in conjunction with stem cell transplantation
- DoD In-Utero Fetal Surgical repair of Myelomeningocele Clinical Trial
- Phase II and Phase III concer clinical trials
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Inpatient Hospital Stays
- Admissions or transfers to skilled nursing facility (SNF), Rehab, long-term acute care(LTAC)
- Notification of acute care admission by the next working day
- Discharge notification
- Concurrent reviews upon request by Humana Military
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Behavioral Health
- Psychoanalysis
- Psychological and neuropsychological testing
- Inpatient hospital
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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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