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 / Orthotics
- Air flotation mattress and/or electric hospital bed
- Augmentative communication device
- Bone growth stimulator
- Chest compression system
- Continuous Glucose Monitor
- Continuous positive airway pressure (CPAP) devices Purchase Only
- Bilevel positive airway pressure (BPAP) devices Purchase Only
- Gait trainers/standers
- Lift devices
- Neurostimulators
- Lightweight, ultralightweight or power wheelchair or scooters
- Prosthetics
- Pumps - Insulin and Implantable
- Ventilators
- Wound vac
- Other
Extended Care Health Option (ECHO) Program
- All services covered under ECHO
Hearing Services
Home Health Care and Home Infusion
- All Services delivered in the home, including all therapy services
Hospice
HYPERBARIC OXYGEN
Inpatient Facilities
- Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities, and Long Term Acute Care (LTAC)
- All behavioral health including emergencies
- All elective medical / surgical admission
- Emergency admissions require notification within 24 hours
Laboratory
- Genetic Testing
- Preservation of Stem Cells
Non-Emergent Transports and Non-Emergent Ambulance
Oral and Enteral Nutritional Therapy
Pain Management and Biofeedback Services
Radiology
- Brain MRI
- Breast MRI
- Spine MRI
- MRA
- Pet Scan
- Cardiac CT Angiography
- CT Colonoscopy
- Other
Proton Beam Therapy
SURGICAL PROCEDURES
- Abortion, elective
- Bariatric
- Cosmetic procedures
- Implantation of pumps and neurostimulators
- In-utero fetal
- Obstructive Sleep Apnea
- Spine
- Transplants, except corneal
- Lung Volume Reduction
- Total Joint Replacements
- Other
Therapies
- All therapies performed in the home
- 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
- Any combination of Physical Therapy and Occupational Therapy greater than 40 visits per episode for beneficiary over age 21
- Speech therapy
NOTE: Speech therapy for Prime and Standard requires an Individualized Education Program (IEP) for beneficiaries ages 3-21.
Unlisted Codes
In order for TriWest to make an appropriate benefit determination, all services with unlisted codes require prior authorization, and must be submitted with a description.
Referrals
Referrals are required for most services for TRICARE Prime beneficiaries if the service is provided by a civilian provider other than the Primary Care Manager (PCM). Active Duty Service Members (ADSMs) must always have a referral for all treatment outside of a Military Treatment Facility (MTF), except for emergencies. Once a referral is approved, the servicing provider may render services not listed on the PAL without further approval from TriWest. An additional referral request is required only if the network provider proposes to use a non-network facility for services. Outpatient services not listed on the PAL and performed in a West Region network facility do not require additional authorization or referral.
There must be a referral from a PCM/MTF to a specialty provider within the previous 180 days or duration of the referral as noted on the initial referral letter.
Authorizations
Authorizations are required for all procedures listed on the PAL for all TRICARE beneficiaries in programs administered by TriWest, including Prime, TRICARE Prime Remote, Standard, Extra, TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult and ECHO.
Authorizations are Required for Services Listed on the PAL
Note that all services must be covered benefits under TRICARE in order to be reimbursed. If a service is not listed on the PAL, authorization is not required. If a referral or authorization is not required, please do not submit a referral or authorization request to TriWest. If your office procedures require that you submit referral or authorization requests for all services, then those requests must be submitted online at www.triwest.com/provider.
Outpatient services rendered by a network provider in a non-network facility require prior authorization; otherwise, a penalty will be applied to the network servicing provider's claim.
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, 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 Tests (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) X-rays
Other Health Insurance (OHI)
TRICARE is always primary for ADSMs. TRICARE is always primary to Medicaid and Indian Health Services. For all other TRICARE beneficiaries with OHI or Medicare, TRICARE is secondary. The beneficiary should contact the OHI carrier or if Medicare, WPS, for questions regarding OHI or Medicare benefits and authorizations. Medicare Advantage members should contact the Medicare Advantage Plan. TRICARE beneficiaries who have OHI or Medicare are not required to obtain prior authorizations for covered services, except for the following services:
- Adjunctive dental care
- All Behavioral Health services (other than primary Medicare and the initial eight self-referred visits annually)
- Extended Care Health Option (ECHO) services
- Solid organ and stem cell transplants
- Speech therapy
