What services require prior authorization?
Quick Answer
Prior authorization is needed for many inpatient stays, some surgeries, specialty services, DME, and certain high-cost procedures regardless of plan.
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Key Takeaways
- Many inpatient services need authorization
- DME and home health require approval
- Provider submits request
- Emergency care authorized retroactively
Detailed Answer
Prior authorization ensures services are medically necessary before you receive them.
Services Requiring Authorization
- Most inpatient hospital admissions
- Inpatient mental health
- Residential treatment centers
- Skilled nursing facility care
- Durable medical equipment (DME)
- Home health care
- Some surgeries and procedures
- Transplants
- Applied Behavior Analysis (ABA)
- Extended physical therapy
How to Get Authorization
- Provider submits request
- TRICARE contractor reviews
- Approval/denial within days
- Emergency care authorized retroactively
If Denied
- Provider can request reconsideration
- You can appeal the decision
- Get care while appealing if urgent
Authorization vs Referral
- Referral: Permission to see specialist
- Authorization: Approval for specific service
- Some services need both
- Prime needs both more often
Related Questions
What's the difference between a referral and prior authorization?
Referrals allow you to see specialists (Prime requirement). Prior authorization is approval needed before certain services regardless of plan.
How do I appeal a TRICARE decision?
Appeal denied claims or coverage decisions within 90 days by submitting a written appeal with supporting documentation to your regional contractor.
What do most military families add to their TRICARE coverage?
Supplemental health insurance is the most common addition — it covers dental, vision, and out-of-pocket costs that TRICARE leaves uncovered. Life insurance and a legal will are also highly recommended.
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