Prior Authorization

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 services
  • Applied behavior analysis
  • Home health services
  • Hospice care
  • Nonemergency inpatient admissions for substance-use disorders or behavioral health
  • Outpatient mental health care beyond the eighth visit
  • Transplants (all solid organ and stem cell)
  • All services covered under the Extended Care Health Option
  • All services covered under the Provisional Coverage Program

Check with your regional contractor for additional requirements and specific processes:

Last Updated 9/2/2016