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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyDHA Special Authorization Policy Update | OpenPaye…
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    ModifiedDHAPolicy 6010.63-M

    Special Authorization Requirements

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    DHA Policy Manual section addressing special authorization requirements, including provider preauthorization obligations, exceptions, and retrospective review.

    Policy Summary
    PayerDHA
    PolicySpecial Authorization Requirements
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateNot provided
    Next Review DateNot provided
    Key ActionObtain preauthorization for liposuction used to treat lipedema-related symptoms.
    SourceLink
    POLICY UPDATE CHANGES

    Revision 7 modified the authorization provision identified as paragraph 1.16.

    Coverage of liposuction for treatment of lipedema-related symptoms was added as a service requiring preauthorization.

    57Policy manual revision
    16Authorization requirements
    1Retrospective review exception
    Day 101SNF authorization timing
    Mar 5, 2019Spravato authorization effective

    Exceptions to Preauthorization Requirements

    Retrospective Review and Dual-Eligible Exception

    The contractor shall obtain the necessary information and perform a retrospective review when TRICARE is the primary payer and preauthorization was not obtained. For dual eligible beneficiaries, these requirements apply when TRICARE is the primary payer.

    Apply the applicable payer-status rule

    • ALL of the following

      • TRICARE is the primary payer for the services.
      • Preauthorization was not obtained.
      • The contractor obtains the necessary information and performs a retrospective review.

        For dual eligible beneficiaries, these retrospective-review requirements apply when TRICARE is the primary payer.

    • ALL of the following

    Policy Summary
    PayerDHA
    PolicySpecial Authorization Requirements
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateNot provided
    Next Review DateNot provided
    Key ActionObtain preauthorization for liposuction used to treat lipedema-related symptoms.
    SourceLink
    On This Page
    Exceptions to Preauthorization RequirementsAuthorization Timing and Effective DatesServices Requiring Authorization

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    • Medicare is the primary payer and TRICARE is the secondary payer.
    • TRICARE relies on, and does not replicate, Medicare’s determination of medical necessity and appropriateness in all circumstances.

    Other Insurance Exception

    The preauthorization requirements do not apply when TRICARE is acting as a secondary payer under the other insurance exception and all of the following conditions are met.

    ALL of the following

    • The other health insurance (OHI) is primary under the provisions of the TRM, Chapter 4, Section 1.
    • Documentation that the OHI processed the claim is submitted with the TRICARE claim.
    • Documentation of the exact amount paid by the OHI is submitted with the TRICARE claim.

    Authorization Timing and Effective Dates

    SNF preauthorization timing
    Applicable careSkilled Nursing Facility (SNF) care received in the United States and U.S. territories for TRICARE dual-eligible beneficiaries
    Preauthorization timingThe TMEP contractor preauthorizes SNF care beginning on day 101, when TRICARE becomes the primary payer.
    Effective dates of serviceThe requirement applies to dates of service beginning June 1, 2010.
    SNF requirement effective date
    General effective dateJune 1, 2010, for dates of service.
    Beneficiaries already inpatientFor beneficiaries who were inpatient on the effective date, preauthorization was required beginning August 1, 2010.
    Applicable populationTRICARE dual-eligible beneficiaries receiving Skilled Nursing Facility care in the United States and U.S. territories.

    Services Requiring Authorization

    Prior Authorization

    Preauthorization Required: Adjunctive Dental Care

    Adjunctive dental care must be preauthorized before care is provided.

    Prior Authorization

    Preauthorization Required: Dental Anesthesia and Institutional Benefit

    Dental anesthesia and institutional benefit services must be preauthorized. See Chapter 8, Section 13.2.

    Prior Authorization

    Authorization Required: ECHO Benefits

    Extended Care Health Option (ECHO) benefits must be authorized in accordance with Chapter 9, Section 4.1.

    Prior Authorization

    Authorization Required: Nonemergency Inpatient Mental Health and SUD Care

    Preadmission and continued-stay authorization is required before nonemergency inpatient mental health services may be cost-shared.

    • Includes Residential Treatment Center (RTC) care.
    • Includes inpatient or residential Substance Use Disorder (SUD) detoxification and rehabilitation.
    Prior Authorization

    Preauthorization Required: Psychoanalysis

    Psychoanalysis must be preauthorized.

    Prior Authorization

    Potential Preauthorization Required: Nonemergency Inpatient Facility Admission

    The Government Designated Authority (GDA) may require preauthorization of admission to nonemergency inpatient facilities.

    Prior Authorization

    Preauthorization Required: Organ and Stem Cell Transplants

    Organ and stem cell transplants must be preauthorized. Authorization remains in effect while the beneficiary continues to meet the specific transplant criteria in the TRICARE Policy Manual or until the approved transplant occurs.

    Prior Authorization

    Preauthorization Required: Home Infusion Therapy

    Infusion therapy delivered in the home must be preauthorized in accordance with Chapter 8, Section 20.1.

    Prior Authorization

    Preauthorization Required: Skilled Nursing Facility Care

    Skilled Nursing Facility (SNF) care received in the United States and U.S. territories must be preauthorized for TRICARE dual-eligible beneficiaries.

    • For dates of service beginning June 1, 2010, the TRICARE Medicare Eligible Program (TMEP) contractor preauthorizes SNF care beginning on day 101, when TRICARE becomes the primary payer.
    • For beneficiaries who were inpatient on the effective date, preauthorization was required beginning August 1, 2010.
    • See the TRICARE Operations Manual, Chapter 7, Section 2, and TRICARE Reimbursement Manual, Chapter 8, Section 1.
    Prior Authorization

    Preauthorization Required: Emerging Services and Supplies

    Provisional coverage for emerging services and supplies must be preauthorized when required, in accordance with Chapter 13, Section 1.1 and the TRICARE Operations Manual, Chapter 7, Section 4.

    Prior Authorization

    Preauthorization Required: Low-Protein Modified Foods

    Medically necessary low-protein modified foods for the treatment of inborn errors of metabolism must be preauthorized in accordance with Chapter 8, Section 7.1.

    Note

    Check Geographic-Area Authorization Requirements

    Each TRICARE contractor may require additional care authorizations not identified in this section, and requirements may differ by geographic area of responsibility.

    • Beneficiaries and providers are responsible for contacting the applicable contractor for a listing of additional authorization requirements in their geographic area.

    Unsupported block type: documentation

    Prior Authorization

    Preauthorization Required: Spravato

    Spravato™ (esketamine) nasal spray requires preauthorization under the medical benefit.

    • See Chapter 7, Section 3.7, and the TRICARE Operations Manual, Chapter 7, Section 2.
    Prior Authorization

    Preauthorization Required: Liposuction for Lipedema

    Coverage of liposuction for the treatment of lipedema-related symptoms requires preauthorization in accordance with Chapter 4, Section 2.1.

    Denial Risk

    Payment Reduction Risk: Failure to Obtain Preauthorization

    Provider payments are reduced when preauthorization requirements are not followed for applicable types of care. See the TRICARE Reimbursement Manual, Chapter 1, Section 28.

    Documentation Required

    Retrospective Review When TRICARE Is Primary

    When preauthorization was not obtained, the contractor must obtain the necessary information and perform a retrospective review when TRICARE is the primary payer for the services.

    • For dual-eligible beneficiaries, these requirements apply when TRICARE is the primary payer.
    • When Medicare is primary, TRICARE relies on Medicare’s determination of medical necessity and appropriateness and does not replicate that determination.