Do I need an authorization?
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When TFL is the primary payer for certain services, you will need preauthorization. When Medicare or other insurance is the primary payer, you will not.
TFL does not make referrals to specialists or other providers.
The provider will handle preauthorization in most cases.
You will need preauthorization for these services when TFL is the primary payer:
- Skilled Nursing Facilities (SNF)
- Hospice when beneficiary only has Medicare Part B
- Extended Health Care Option
- Inpatient Mental Health and Substance Use Disorder
- Laboratory Developed Tests
- Femoroacetabular Impingement (FAI)
- Cancer Clinical Trials (CCT), 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)
- Adjunctive Dental
- Home Health PPS
- Dental Anesthesia and Institutional Benefits
- Electroconvulsive Therapy (ECT)
- Transcranial Magnetic Stimulation (TMS)
- Applied Behavioral Analysis (ABA) services, contact regional contractor for authorization.
TFL will not approve services after the fact. If five days have passed since the service, the provider must submit a claim. They must include all supporting documents and send the claim through the website or by fax (608-301-2114 or 608-301-3100). TFL may reduce payment 10% when services are not approved in advance, however ABA services will not be considered without an authorization.
How do I submit a request for authorization?
The most reliable way for providers to send authorization requests is through the request form on our website. Always use the authorization request form as a cover sheet and attach documentation.
Providers can also fax the request form and accompanying documentation to 608-301-3226. Please allow 24 hours for the fax to get into our system.
Nurses have up to five business days to complete a review. They will process forms in the order received. TFL will send the provider fax or a secure email if they do not have a fax. If there is no fax or email, TFL will mail the authorization letter.
Skilled Nursing Authorization Requests
TRICARE For Life requires preapproval 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. This includes Medicare.
Providers will need to fill out the SNF Authorization Form, along with:
- Most Recent Hospital History and Physical (H&P)
- Current Physician Orders
- If admit/re-admit, Physician Admitting Orders
- Documentation of skilled care
TFL follows Medicare Part A guidelines for skilled care, excluding established feeding tubes/enteral feedings.
TFL ask that you send only this information. This will help us:
- Process your request efficiently
- Avoid processing delays
- Eliminate retrospective reviews and payment reductions
TFL will complete your request within five business days from the date of receipt.
How do I find out when TFL approves my authorization?
TFL will send you a confirmation letter upon completion. If you do not have a fax, TFL will send the letter by secure email, and mail a copy to you and beneficiary. TFL will complete all authorizations within five business days.
How long will my authorization be valid?
This can vary, depending on a patient’s needs, but authorizations are for a maximum of 30 days. If you need care beyond the 30 days, you will need to request a new authorization.
How do I get an authorization to admit?
TFL will never give an authorization to admit. TFL follows Medicare A guidelines for skilled care, excluding established feeding tubes/enteral feedings. If necessary, admit or transfer the patient. Begin skilled care right away. Do not wait for approval. Document the skilled care you are currently providing in your facility and send it to TFL for approval.
What happens if I did not request an authorization? Can I get a retroactive authorization?
Retro-authorizations are not provided for in or out of network providers. 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 may be a payment reduction of 10% for not having an authorization.
Do I have to do anything if skilled care ends?
Visit the forms menu and obtain a Notice of Non-Coverage letter. Provide it to the resident or POA for a signature and submit it with the original authorization 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.
Can I appeal a denied authorization?
Yes, you have the right to appeal denied authorizations. Appeals will be handled through the Appeals department. You can mail or fax your appeal request to:
1707 W. Broadway
Madison, WI 53713