Does Medicare Tricare beneficiary require authorization

Beneficiaries Using Medicare and TRICARE

Beneficiaries using Medicare as their primary payer are not required to obtain referrals or prior authorization from TriWest for inpatient or outpatient behavioral health care services. These beneficiaries should follow Medicare rules for services requiring authorization. They may self-refer to any network or non-network provider who accepts Medicare. When behavioral health care benefits are exhausted under Medicare, TRICARE becomes the primary payer, and prior authorization from TriWest is then required.

For more information, contact the Medicare Plan Administrator at 1-800-633-4227.

Nonavailability Statements

A nonavailability statement (NAS) is required for all nonemergency behavioral health care admissions. A NAS is a certification from an MTF stating it cannot provide a specific required service at a particular time to a non-enrolled beneficiary (i.e., a non-TRICARE Prime beneficiary).

Providers should advise TRICARE beneficiaries to check with the Beneficiary Counseling and Assistance Coordinator (BCAC) at the local MTF to find out if a NAS is required before obtaining nonemergency behavioral health care inpatient services. A NAS does not take the place of an authorization for those services requiring prior authorization