Certain requested services, procedures, or admissions require prior authorization. Prior authorizations are based on medical necessity and are not a guarantee of payment. When a TRICARE provider fails to obtain prior authorization, or exceeds the scope of an approved referral/authorization, he or she may
incur penalties.
The prior authorization list in Figure 7.2 became effective on April 1, 2009. For behavioral health care prior authorizations, call ValueOptions, Inc., at 1-800-700-8646.
Make sure to include the following information:
- Sponsor identification (ID), SSN, address
- Patient name, date of birth, relationship to sponsor
- Admitting hospital, date, and time; physician Tax Identification Number, name, and mailing address
- Clinical conditions for surgery, including Current Procedural Terminology (CPT®) codes
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 as an outpatient observation stay for up to 48 hours. If, after 48 hours, the patient must continue as an inpatient, you must notify Humana Military.
Figure 7.3 provides tips for submitting requests for prior authorizations.
Special Cases for Prior Authorizations
Prior Authorization for Active Duty Service Members
ADSMs require prior authorization (except for emergencies) 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 care services, family counseling, and smoking cessation programs.
Providers who do not obtain prior authorizations when required, or who exceed the scope of approved prior authorizations, risk not being paid or being charged a penalty.
Bariatric Surgery Centers of Excellence
Referring beneficiaries to Bariatric Surgery Centers of Excellence 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 implemented a Medicare National Coverage Decision that allows coverage for bariatric surgery only in approved facilities.
Approved facilities are certified by the American College of Surgeons as Level 1 Bariatric Surgery Centers or certified by the American Society for Bariatric Surgery as Bariatric Surgery Centers of Excellence.
Humana Military has worked to bring these centers into the TRICARE South Region network. Please carefully consider referring bariatric surgery candidates to certified facilities. For TRICARE beneficiaries in the South Region, bariatric surgery requires prior authorization from Humana Military.
Referral/Authorization Autofax Confirmation
Humana Military’s referral/authorization staff sends an autofax confirmation to providers to ensure they receive notifications of confirmed referrals or authorizations for TRICARE Prime beneficiaries.
The autofax (see Figure 7.4) is:
- Generated to the requesting provider. It may include a copy to the PCM on file, the specialist or group selected for the service, and the facility that may be used for services performed.
- Issued at the time the referral/authorization has been approved. In most cases, providers receive this fax confirmation well before the TRICARE beneficiary makes an appointment.
- Meant to be retained by your office until the TRICARE beneficiary makes an appointment. At that time, place it in the patient’s chart.
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 the number appears on your referral requests.
