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.
Interpretation or Explanation of Results (collateral visits)
Behavioral health sessions after self-referred initial visit & 8 sessions (Pastoral Counselors, Licensed Professional Counselors and Mental Health Counselors require a physician referral)
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.
Emergency Services
Eight routine outpatient Behavioral Health visits per beneficiary, per fiscal year
Labs (except for genetic testing, which requires authorization)
Radiographs
Ultrasounds — Only covered if medically necessary. Screening to determine the baby’s sex is not covered.
Dexa Scans — Screening is not covered.
CT Scans — Screening is not covered.
Durable Medical Equipment (DME) not on the Prior Authorization List does not require prior authorization.
Cardiac stress tests and myocardial imaging
Intravenous Pyelogram (IVP)
Upper gastrointestinal (UGI)
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.
Colonoscopy — Screening and diagnostic
Esophagogastroduodenoscopy (EGD)
Pulmonary Function Test (PFT)
Eye exams — Refer to www.triwest.com, Provider Connection, for more information on the vision benefit.
Annual Pap smear
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
Home health services
Hospice services
Solid organ and stem cell transplants
Services after the beneficiary has exhausted the OHI benefits
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