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Preauthorization review is only required for TRICARE For Life (TFL) beneficiaries when TFL is the primary payer for the specific services listed below. If Medicare or another primary insurance covers the care, then no authorization review is necessary.
TFL does not issue referrals to specialists or other providers, only preauthorization for the services indicated below.
Authorization is normally obtained by your provider of service. Please contact your provider to find out if the authorization request has already been submitted.
The following services require preauthorization when TFL is the primary payer:
- Skilled Nursing Facilities (SNF)
- Hospice when beneficiary only has Medicare B
- Extended Health Care Option
- Laboratory Developed Tests
- Femoroacetabular Impingement (FAI)
- Cancer Clinical Trials (CCT) are reviewed for approvals by the authorization staff
- IVIG (Intravenous Immunoglobulin) Drugs
- AAT (Alpha-1 Antitrypsin) Drugs
- Low Protein Modified Foods (LPMF) for Inborn Errors of Metabolism (IEM)
- Outpatient Mental Health Care (to include Partial Hospitalization Programs (PHPs), Intensive Outpatient Programs (IOPs), Opioid Treatment Programs (OTPs), Office-Based Opioid Treatment (OBOT), Transcranial Magnetic Stimulation (TMS), Electroconvulsive treatment, and outpatient mental health visits) will continue to require authorization for all TRICARE® for Life (TFL) beneficiaries. All outpatient mental health visits each year will require an authorization.
Retro-Authorizations are not provided. If the service has been performed greater than 5 business days ago, the provider will need to submit a claim with supporting documentation for a review to the claim’s department via the website or via fax at 608-301-2114 or 608-301-3100. There will be a payment reduction of 10% for not having an authorization.
How do I submit a request for authorization?
The most reliable way for providers to send information is to send the authorization request form specific to the request and accompanying documentation by using this website. There is an easy to follow tutorial for the provider if they go to “Create a Provider Account” and look at the top right of that screen. Always use the authorization request form as a cover sheet.
To send by fax, fax the authorization request form and accompanying documentation to 608-301-3226. It takes at least 24 hours for the fax to get into our system.
To send by mail, send all authorization requests and accompanying documentation to:
TDEFIC - MR Authorizations
1707 W. Broadway
P.O. Box 7934
Madison, WI 53713
NOTE: Sending to a physical address, by any means, is not recommended. All incoming mail goes to a general mailroom to be distributed throughout the entire company and can take multiple days. Please put the date it was sent and the date it was due to arrive on the authorization request form. Website submission or fax is highly suggested.
The authorization nurses have up to five business days to complete a review and they are done in the order in which they are received. The provider will receive a fax, or a secure email if they do not have a fax. If there is no fax or email, the authorization letter will be mailed.
Skilled Nursing Authorization Requests
TRICARE For Life requires preauthorization for Skilled Nursing Facility (SNF) care once TFL becomes primary payer. By law TFL is the last payer after all other insurance or benefit plans, to include Medicare.
To obtain SNF preauthorization, please have the provider fill out the Skilled Nursing Facility (SNF) Authorization Form along with the following information.
- Most Recent Hospital History and Physical (H&P)
- Current Physician Orders
- If admit/re-admit, Physician Admitting Orders
- Documentation of skilled care
We follow Medicare Part A guidelines for skilled care, excluding established feeding tubes/enteral feedings.
To more efficiently process your preauthorization request, avoid processing delays, and eliminate the need for retrospective reviews and payment reductions, we kindly ask that you submit only the required information listed above. We will complete your authorization request within 5 business days from the date of receipt.
How do I find out if my authorization is approved?
The provider will receive a confirmation letter via fax once the authorization has been completed. If the provider does not have a working fax, he/she will receive a secure email. It will also be mailed to the provider and beneficiary. 100% of all authorizations will be completed within five business days.
How long will my authorization be good for?
This can vary, depending on the patient’s needs but an authorization will only be granted for up to a maximum of 30 days. If additional care is needed beyond the 30 days, a new authorization will need to be requested.
How do I get an authorization to admit?
TFL will never give an authorization to admit. We follow Medicare A guidelines for skilled care, excluding established feeding tubes/enteral feedings. Admit/transfer the resident and initiate skilled cares immediately. Provide documentation of the skilled care he/she is actively receiving in your facility for an authorization. Do not delay initiating skilled care waiting for the authorization.
What happens if I did not request an authorization? Can I get a retroactive authorization?
Retro-authorizations are not provided. If the service has been performed greater than 5 business days ago, the provider will need to submit a claim with supporting skilled care documentation for a review to the claim’s department via the website or via fax at 608-301-2114 or 608-301-3100. There will be a payment reduction of 10% for not having an authorization.
Do I have to do anything if skilled care ends?
Visit the website and obtain a Notice of Non-Coverage letter. Provide it to the resident or POA for a signature and submit it with the request form as a cover sheet.
How do I get a denial letter?
Submit the TRICARE For Life Notice of Non-Coverage letter and you will receive instructions on what to submit to get a formal denial letter.
Do I have appeal rights on unfavorable authorization determinations?
Yes, you will have formal appeal rights on denied authorizations, and those appeals will be handled through the Appeals department. The appeal request can be mailed or faxed to:
1707 W. Broadway
Madison, WI 53713
Fax: (608) 301-3226