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Prior Authorization List

All services listed below, provided by TRICARE civilian providers, must be reviewed for medical necessity and require prior authorization for all TRICARE programs administered by TriWest.

View a comprehensive list of codes requiring prior authorization

BEHAVIORAL HEALTH / OUTPATIENT

  • All Psychological and Neuropsychological testing (Inpatient & Outpatient)
  • Behavioral health sessions after self-referred initial evaluation & 8 sessions (Pastoral Counselors, Licensed Professional Counselors and Mental Health Counselors require a physician referral)
  • Crisis intervention (CPT codes 90808 and 90809)
  • Electroconvulsive therapy
  • Interpretation or Explanation of Results (collateral visits)
  • Psychoanalysis
  • Medication management exceeding twice/month

DENTAL

  • Adjunctive dental (including anesthesia); and/or
  • All dental care provided by a dentist or oral surgeon

DRUGS AND BIOLOGICALS

  • Certain Chemotherapy drugs
  • Injectables/Home Infusion
  • A complete list of these drugs is also available on the Prior Authorization Drug List at www.triwest.com/provider.
NOTE: NDC code is required on all prior authorization requests

DURABLE MEDICAL EQUIPMENT (DME) / PROSTHETICS

  • Air flotation mattress and/or electric hospital bed
  • Augmentative communication device
  • Bone growth stimulator
  • Chest compression system
  • Continuous Glucose Monitor
  • Gait trainers/standers
  • Lift devices
  • Neurostimulators
  • Obstructive Sleep Apnea Devices
  • Orthotics
  • Power wheelchair or scooters
  • Prosthetics
  • Pumps - Insulin and Implantable
  • Wound vac
  • Other

ENTERAL FEEDINGS



EXTENDED CARE HEALTH OPTION (ECHO) PROGRAM

All services covered under the program

GENETIC TESTING



HEARING AIDS



HOME HEALTH CARE



HOSPICE



HYPERBARIC OXYGEN



INPATIENT FACILITIES

  • All behavioral health including emergencies
  • All elective medical / surgical admissions
  • Emergency admissions require notification within 24 hours

NON-EMERGENT TRANSPORTS AND NON-EMERGENT AMBULANCE



PAIN MANAGEMENT AND BIOFEEDBACK SERVICES



RADIOLOGY

  • Brain MRI
  • Breast MRI
  • Pet Scan
  • Spine MRI
  • Other

SURGICAL PROCEDURES

  • Abortion, elective
  • Bariatric
  • Cosmetic procedures
  • Hysterectomies
  • Implantation of pumps and neurostimulators
  • In-utero fetal
  • Obstructive Sleep Apnea
  • Spine
  • Transplants, except corneal
  • Other

THERAPIES

  • Occupational therapy greater than 20 visits per episode for beneficiary over age 21
  • Physical therapy greater than 20 visits per episode for beneficiary over age 21
  • Speech therapy
NOTE: Speech therapy for Prime and Standard requires an individual Education Plan (IEP) for beneficiaries ages 3-21.

UNLISTED CODES

In order for TriWest to make an appropriate benefit determination, all care billed with an unlisted code(s) must include a description of the item and pricing, if available, and be prior authorized with the exception of unlisted supplies with a cumulative amount of $100.00 or less.



REFERRALS

Referrals are necessary when a Primary Care Manager (PCM) cannot provide the necessary services. Active Duty Service Members (ADSMs) must always have a referral for all care outside of a Military Treatment Facility (MTF), except for emergencies. Referrals are required for most services for Prime and TRICARE Prime Remote (TPR) beneficiaries, even if the service is not listed on the Prior Authorization List. Referrals are not the same as authorizations. Refer to the provider handbook for additional information.

AUTHORIZATIONS

Authorizations are required for all procedures listed on the Prior Authorization List for all TRICARE beneficiaries in programs administered by TriWest, including Prime, TPR, Standard, Extra, TRICARE Reserve Select, and ECHO.

AUTHORIZATIONS ARE NOT REQUIRED FOR SERVICES NOT LISTED ON THE PRIOR AUTHORIZATION LIST

Please note that all services must be covered benefits under TRICARE in order to be reimbursed. However, not all services require a prior authorization from TriWest. The following is a partial list of services which do not require authorization.

  • Annual Pap smear
  • Cardiac stress tests and myocardial imaging
  • Colonoscopy — Screening and diagnostic
  • CT Scans — Screening is not covered.
  • Dexa Scans — Screening is not covered.
  • Durable Medical Equipment (DME) not on the Prior Authorization List
  • Eight routine outpatient Behavioral Health visits per beneficiary, per fiscal year
  • Esophagogastroduodenoscopy (EGD)
  • Eye exams — Refer to www.triwest.com, Provider Connection, for more information on the vision benefit.
  • Intravenous Pyelogram (IVP)
  • Labs (except for genetic testing, which requires authorization)
  • Mammograms — Annually for those over age 39. If patient is at high risk for breast cancer, a baseline mammogram is appropriate at age 35, then annually thereafter.
  • Pulmonary Function Test (PFT)
  • Radiographs
  • Services in the Emergency Room
  • Ultrasounds — Only covered if medically necessary. Screening to determine the baby’s sex is not covered.
  • Upper gastrointestinal (UGI)

OTHER HEALTH INSURANCE (OHI)

TRICARE is always primary for ADSMs. For all other TRICARE beneficiaries with OHI, TRICARE is secondary. TRICARE beneficiaries who have OHI are not required to obtain prior authorizations for covered services, except for the following services:

  • Adjunctive dental care
  • All Behavioral Health services, except for the initial eight self-referred visits annually
  • Extended Care Health Option (ECHO) services
  • Solid organ and stem cell transplants


This page has been updated for services provided on or after 4/15/08; however, the specific codes requiring authorization may be updated monthly.

Form Number: HO440026PRW0308
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