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TRICARE: Don’t get stuck with the bill

  • Published
FALLS CHURCH, Va. --  When a TRICARE beneficiary needs hospital care, he or she can usually be confident that the benefit will cover everything involved with inpatient care. Doctors may order lab tests, X-rays or medication. And afterwards, they may call for Magnetic Resonance Imaging. But wait ... Too much confidence could mean that the patient ends up paying for that MRI. Why?

Because in some cases, TRICARE beneficiaries need preauthorization to get the healthcare their doctors recommend. Those who are in TRICARE should ask their regional contractors about the specific medical care being considered before scheduling an appointment to be sure TRICARE coverage will apply.

"We want to give beneficiaries all the coverage they need," said Army Maj. Gen. Elder Granger, Deputy Director, TRICARE Management Activity. "Failure to get preauthorization limits our ability to offer that coverage."

TRICARE beneficiaries may need preauthorization for any procedure that is not routine, and such things aren't always obvious. For example, TRICARE now covers anesthesia services and associated costs for dental treatment for beneficiaries with developmental, mental or physical disabilities, and children age 5 or under. This is a valuable new benefit, but it's not routine and requires preauthorization.

Standard beneficiaries in particular may forget to seek preauthorization because they are used to self-referral. They book their own appointments with primary care providers and specialists. There is no all-inclusive list of procedures that call for preauthorization. However, some common examples include adjunctive dental care, some medications, home healthcare and inpatient admissions for substance abuse or behavioral health. Each region has its own requirements, so services that need preauthorization in one region may not in another.
If beneficiaries have other health insurance, they need to follow the rules of the other plan. Generally, they won't need preauthorization for TRICARE-covered services that would otherwise require it. Exceptions include adjunctive dental care, the Extended Care Health Option, hospice, stem cell and organ transplants, and some behavioral health care services. 

To verify if preauthorization is necessary, beneficiaries can contact their regional contractors: North Region, 1-877-TRICARE (1-877-874-2273); South Region, 1-800-444-5445; and West Region, 1-888-874-9378.