Prior Authorization
PA
Quick Definition
Approval required from TRICARE before receiving certain services or medications.
Key Takeaways
- Required approval before receiving certain services or medications
- Your provider typically submits the authorization request
- Emergency care never requires prior authorization
Full Definition
Prior authorization is the process of obtaining approval from TRICARE before receiving certain healthcare services, procedures, or medications. This requirement ensures that the proposed care is medically necessary and meets TRICARE coverage guidelines.
Services that may require prior authorization: • Certain surgical procedures • Advanced diagnostic imaging (MRI, CT scans) • Specialty medications and non-formulary drugs • Durable medical equipment • Inpatient hospital admissions (non-emergency) • Some behavioral health services • Certain therapy programs
How prior authorization works: • Your provider submits a request to TRICARE • TRICARE reviews medical necessity • Approval, denial, or request for more information is issued • Approved services must be rendered within the authorization period
Important considerations: • Emergency care never requires prior authorization • Your provider typically handles the request process • Denials can be appealed with additional documentation • Failure to obtain required authorization may result in higher costs or denial of coverage
Prior authorization protects beneficiaries by ensuring care is appropriate and covered, while helping control overall healthcare costs within the TRICARE system.
Helpful Tips
- Confirm prior authorization is obtained before scheduling non-emergency procedures to avoid unexpected costs.
- If authorization is denied, ask your provider about the appeals process for reconsideration.
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 find a TRICARE provider?
Use the online provider directory on your regional contractor's website or call them directly for assistance.
What is the TRICARE formulary?
The TRICARE formulary is the list of covered medications organized into tiers, with generic drugs in lowest tier and specialty drugs in highest tier.
How does TRICARE cover specialty medications?
Specialty medications for complex conditions are covered through Accredo specialty pharmacy with prior authorization and may have assistance programs.
Does TRICARE cover compounded medications?
TRICARE covers some compounded medications with restrictions. Coverage requires medical necessity and may need prior authorization for certain compounds.
Does TRICARE cover residential treatment programs?
TRICARE covers residential treatment for mental health, substance abuse, and eating disorders when medically necessary and authorized.
How does TRICARE cover psychiatric medications?
Psychiatric medications are covered under TRICARE pharmacy benefit with standard copays. Some require prior authorization or step therapy.
What is TRICARE's policy on gender-affirming care?
TRICARE coverage for gender-affirming care is limited. Mental health counseling and hormone therapy may be covered, but surgical procedures are generally not covered for most beneficiaries.
Does TRICARE cover nursing home care?
TRICARE covers skilled nursing facility care on a short-term basis when medically necessary after hospitalization. Long-term custodial care and assisted living are not covered.
Does TRICARE cover weight loss programs?
TRICARE covers medically necessary weight loss treatments including bariatric surgery (with strict criteria), nutrition counseling, and obesity screening. Commercial weight loss programs are not covered.
How many physical therapy visits does TRICARE allow?
TRICARE does not impose a strict limit on physical therapy visits. However, continued treatment must be medically necessary, and authorization may be required for extended courses of care.
Does TRICARE cover genetic testing?
TRICARE covers genetic testing when medically necessary, including BRCA testing for cancer risk, prenatal genetic screening, and testing for hereditary conditions when ordered by a provider.
What substance abuse treatment does TRICARE cover?
TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, and medication-assisted treatment (MAT) for alcohol and drug use disorders.
Does TRICARE cover weight loss surgery?
Yes, TRICARE covers bariatric surgery including gastric bypass and sleeve gastrectomy when specific medical criteria are met and pre-authorization is obtained.
Does TRICARE cover hearing aids?
Yes, TRICARE covers hearing aids and related services when prescribed by an authorized provider for diagnosed hearing loss.
Does TRICARE cover cosmetic surgery?
TRICARE does not cover cosmetic surgery unless it is reconstructive surgery required for functional reasons or to correct a condition caused by disease, injury, or congenital defect.
Does TRICARE cover genetic testing?
TRICARE covers genetic testing when medically necessary for diagnosing conditions, guiding treatment decisions, or screening for hereditary disorders with appropriate clinical indications.
Does TRICARE cover bariatric surgery?
Yes, TRICARE covers bariatric surgery for beneficiaries who meet strict medical criteria including BMI requirements, failed conservative treatment, and pre-authorization.
Does TRICARE cover breast reduction?
TRICARE covers breast reduction surgery when it is medically necessary to treat physical symptoms such as chronic pain, skin infections, or nerve damage caused by disproportionately large breasts.
Does TRICARE cover orthotics?
Yes, TRICARE covers custom orthotics and orthotic devices when prescribed by a TRICARE-authorized provider for a diagnosed medical condition.
Does TRICARE cover prosthetics?
Yes, TRICARE covers prosthetic devices including artificial limbs, breast prostheses after mastectomy, and other prosthetic appliances when medically necessary.
Does TRICARE cover home health care?
Yes, TRICARE covers home health care services including skilled nursing, physical therapy, and medical social services when a beneficiary is homebound and meets medical necessity criteria.
Does TRICARE cover skilled nursing facility care?
Yes, TRICARE covers skilled nursing facility (SNF) care when medically necessary, typically following a hospital stay, with pre-authorization required.
Does TRICARE cover durable medical equipment?
Yes, TRICARE covers durable medical equipment (DME) such as wheelchairs, CPAP machines, hospital beds, and oxygen equipment when medically necessary and prescribed by a provider.
Does TRICARE cover ambulance services?
Yes, TRICARE covers ambulance services (ground and air) when medically necessary for emergency transport or interfacility transfers that require medical monitoring.
Does TRICARE cover clinical trials?
TRICARE covers routine patient care costs associated with qualifying clinical trials but does not pay for the experimental treatment or investigational items themselves.
Does TRICARE cover substance abuse treatment programs?
Yes, TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, medication-assisted treatment, and intensive outpatient programs.
Does TRICARE cover autism therapy?
Yes, TRICARE covers autism spectrum disorder (ASD) services including Applied Behavior Analysis (ABA), speech therapy, occupational therapy, and diagnostic evaluations.
Does TRICARE cover TMJ treatment?
TRICARE covers TMJ (temporomandibular joint) disorder treatment including diagnostic evaluation, physical therapy, and oral appliances. Surgical treatment requires pre-authorization.
Does TRICARE cover erectile dysfunction treatment?
Yes, TRICARE covers erectile dysfunction (ED) treatment including diagnostic evaluation, medications, and certain devices when the condition has an organic (medical) cause.
What is the TRICARE formulary?
The TRICARE formulary is the list of prescription medications approved and covered under the TRICARE pharmacy benefit, organized into tiers that determine copay amounts.
How to appeal a TRICARE denial?
Submit a written appeal to your regional contractor within 90 days of the denial, including your explanation, supporting medical records, and a provider's letter of medical necessity.
How to get TRICARE authorization?
Your provider submits a pre-authorization request to TRICARE for services that require approval before treatment. The regional contractor reviews and responds within specified timeframes.
Related Terms
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