What does it mean to get prior authorization? Getting prior authorization means you’re getting the care approved by your regional contractor before you actually go to an appointment and get the care.
- If you have a referral, then your provider gets prior authorization at the same time.
- If you’re not required to get referrals, you should know what services need prior authorization.
When care is approved:
- Your regional contractor sends you and your provider an authorization letter with specific instructions
- Schedule your appointment with the provider listed in the authorization letter
- Contact your regional contractor if you need to find another provider.
- You must get care under the authorization before it expires or you’ll need to get the care re-approved
Active Duty Service Members
You must have prior authorization for all specialty care. You also need a fitness-for-duty review for:
- Maternity care
- Physical therapy
- Mental health
- Family counseling
- Smoking cessation programs
All Other Beneficiaries Enrolled in a TRICARE Prime Plan
- You must have prior authorization for all specialty care.
- Your primary care manager gets your referral and prior authorization at the same time.
All Other Beneficiaries
Are you using any of the following plans?
- TRICARE Standard and Extra
- TRICARE Standard Overseas
- TRICARE Reserve Select
- TRICARE Retired Reserve
- TRICARE For Life
- TRICARE Young Adult-Standard
You must get prior authorization from your regional contractor for the following services:
- Adjunctive dental care
- Applied behavioral analysis
- Home health services (only available in the U.S. and U.S. Territories)
- Hospice care (only available in the U.S. and U.S. Territories)
- Nonemergency inpatient admissions for substance-use disorders or behavioral health
- Outpatient behavioral health care beyond the eighth visit
- Transplants (all solid organ and stem cell)
- TRICARE Extended Care Health Option services
Check with your regional contractor for additional requirements and specific processes:
Always try to see a network provider first!
Network providers can't:
- Ask you to sign a document to make you pay for authorized services.
- Ask you to sign a document to make you pay for any part of the service not covered by TRICARE.
- Refuse to see you because you won’t sign such a document.