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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). The prior authorization list in Figure 7.1 became effective on April 1, 2009. 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.

For behavioral health care prior authorizations, call ValueOptions at 1-800-700-8646.

All other prior authorizations may be requested one of three ways:
  1. Submit requests from the MyHMHS for Providers portal.
  2. Fax a completed PRAF to 1-877-548-1547.
  3. Call Humana Military’s IVR line at 1-800-444-5445.
The services listed in Figure 7.1 require prior authorization for all TRICARE beneficiaries except ADSMs. For information about obtaining prior authorization for ADSMs, see “Prior Authorization for Active Duty Service Members”.

Figure 7.1 Prior Authorization List for the South Region (Updated April 1, 2009)

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
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

Centers of Excellence for Bariatric Surgery

Referring beneficiaries to Centers of Excellence 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 & Medicaid Services Web site.

Humana Military has worked to bring these centers into the TRICARE South Region 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.
    

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 care 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.

Tips for Submitting Authorizations

The quickest way to submit a request for inpatient and outpatient prior authorization is online via the “MyHMHS for Providers”. In many cases, there will be an immediate response and confirmation. You may also fax the request, including clinical information, or call Humana Military’s IVR line at 1-800-444-5445. Make sure you have the following information:
  • Sponsor identification (ID), SSN, address
  • Patient name, date of birth, relationship to sponsor
  • Admitting hospital, date, and time; physician tax ID, name, and mailing address
  • Clinical conditions for surgery, including Current Procedural Terminology (CPT®) codes
You may check the status of your prior authorization request online at the MyHMHS for Providers Portal or by calling the Humana Military IVR line at 1-800-444-5445. 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.

Referral/Authorization Autofax Confirmation

Humana Military’s referral/authorization staff sends an autofax confirmation to providers to ensure that they have received notification of a confirmed referral or authorization for a TRICARE Prime beneficiary.

The autofax is generated to the requesting provider and 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.

The autofax confirmation is 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.

If this is an autofax confirmation for a new patient, your office should retain this item until the TRICARE beneficiary makes an appointment and then place it in the new patient chart.

To ensure timely receipt of autofax transmissions it is 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 the number appears on your referral request.

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Last Reviewed: August 9, 2010