Tricare Help: Negotiating Preauthorization & ‘Medical Necessity’

 In Tricare

Q. We’re an active-duty family on Tricare Prime. Our dependent daughter received a referral for surgery. After it was done, the doctor called to inform her the payment had been denied by Tricare, stating that Tricare is not insurance, but rather a benefit, and noting that “a referral is not a guarantee of payment.” The doctor said she sent a letter of appeal to Tricare and that was denied, too. I have never heard of this. Can you shed any light?

A. In your specific case, Tricare officials say that coverage of your daughter’s surgery was denied because the Tricare managed-care contractor for your region did not consider the surgery “medically necessary.” Officials said this particular procedure should have received a “medical necessity review” from that contractor before the surgery occurred.

The Code of Federal Regulations that governs Tricare states that referral requests (also known as consultation requests) for specialty care for Tricare Prime beneficiaries must be submitted by the beneficiary’s primary care manager.

Beneficiaries don’t need medical necessity preauthorization to obtain consultation appointments, but in some cases — including invasive surgery — actually moving forward with the procedure itself does require medical necessity preauthorization from the beneficiary’s regional Tricare contractor.

It appears that you did not get that preauthorization from your managed-care contractor, which is why payment was denied.

As to whether Tricare is a “benefit” or “insurance,” the Code of Federal Regulations states that Tricare “is a program of medical benefits provided by the U.S. Government under public law to specified categories of individuals.”

“Although similar in structure in many of its aspects, Tricare is not an insurance program in that it does not involve a contract guaranteeing the indemnification of an insured party against a specified loss in return for a premium paid. Further, Tricare is not subject to those state regulatory bodies or agencies that control the insurance business generally.”

Tricare also is not affected by and has no integral links to the Affordable Care Act. Tricare is governed by separate and distinct legislation under the purview of the secretary of defense.

Q. My husband is retired after 25 years in the Army Reserve and is now a “gray area” retiree. I am older than he is. Do I have to wait until his retirement benefits officially begin before I become eligible for Tricare?

A. Until your husband leaves the gray area and becomes eligible for full military retirement benefits, he and you are ineligible for “ordinary” Tricare. However, until then, both of you may be eligible for Tricare Retired Reserve, a relatively new option designed specifically for gray-area retirees and their families. Unlike ordinary Tricare, TRR requires payment of monthly premiums, and there are other restrictions as well. More information is online.

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