Do I need an authorization?
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)
- Transplants
- 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)
- Psychoanalysis
- 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). TFL may reduce payment 10% when services are not approved in advance, however ABA services will not be considered without an authorization.
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.
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 claims department via the website or via fax at 608-301-2114. 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.