Prior Authorization List (PAL)

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
• Gait trainers/standers
• Lift devices
• Neurostimulators
• Power wheelchair or scooters
• Prosthetics
• Pumps - Insulin and Implantable
• Wound vac
• Other

EXTENDED CARE HEALTH OPTION (ECHO) PROGRAM

• All services covered under the program

HEARING SERVICES

HOME HEALTH CARE AND HOME INFUSION

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 admissions
• 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

SURGICAL PROCEDURES

• Abortion, elective
• Bariatric
• Cosmetic procedures
• Hysterectomies
• Implantation of pumps and neurostimulators
• In-utero fetal
• Obstructive Sleep Apnea
• Spine
• Transplants, except corneal
• Lung Volume Reduction
• Total Joint Replacements
• 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 required when a Primary Care Manager (PCM) cannot provide the necessary services. 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.

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.

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, and ECHO.

AUTHORIZATIONS ARE REQUIRED FOR SERVICES LISTED ON THE PRIOR AUTHORIZATION LIST

If a service is not listed on the PAL, authorization is not required. Note that all services must be covered benefits under TRICARE in order to be reimbursed.

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 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. TRICARE is always primary to Medicaid and Indian Health Services. 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 (with the exception of the initial eight self-referred visits annually)
• Extended Care Health Option (ECHO) services
• Solid organ and stem cell transplants

Form Number: FO-64-2009