Pre-Authorization

Pre-authorization (also called prior authorization or precertification) is the process of obtaining advance approval from TRICARE before receiving certain healthcare services, procedures, or medications. Pre-authorization confirms that the proposed care is medically necessary and will be covered by TRICARE.

Services commonly requiring pre-authorization: • Non-emergency inpatient hospital admissions • Certain outpatient surgeries and procedures • Advanced imaging (MRI, CT, PET scans) • Durable medical equipment over certain cost thresholds • Non-formulary medications • Behavioral health inpatient admissions • Skilled nursing facility stays • Home health care services

Pre-authorization process: • Your provider submits a request with clinical documentation • TRICARE reviews for medical necessity • Decision is typically made within 5 business days • Urgent requests receive expedited review • Approval specifies the authorized service and timeframe

What happens without required pre-authorization: • Claim may be denied entirely • Beneficiary may be responsible for full cost • Retroactive authorization may be available in limited circumstances • Emergency services are always exempt from pre-authorization

Your provider typically handles the pre-authorization process. Always confirm that required approvals are in place before receiving scheduled care to avoid unexpected costs.