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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 Authorization List for the South Region (Effective for 2011)
| 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 |
Concurrent reviews upon request by Humana Military |
| Bariatric surgery |
Discharge notification |
| Department of Defense (DoD) In-Utero Fetal Surgical repair of Myelomeningocele Clinical Trial |
Notification of acute care admission by the next working day |
| Educational interventions under the Enhanced Access to Autism Services Demonstration |
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| Extended Care Health Option (ECHO) services |
Behavioral Health |
| Home health services, including home infusion |
All nonemergency inpatient admissions for behavioral health care or substance use disorder |
| Hospice |
Partial hospitalization programs (psychiatric and substance use disorder) |
| Phase II and Phase III cancer clinical trials |
Psychoanalysis |
| Transplants (solid organ and stem cell, not corneal transplant) |
Residential treatment center programs |
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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