Also, if the authorization approval letter indicates that services are “NOT APPROVED” because “…TriWest has not received a referral from the Primary Care Manager (PCM) or from a Military Treatment Facility (MTF) provider for this specialty within the previous 180 days or the time period noted in the initial referral,” then the services will pay under POS unless the beneficiary obtains a referral from their PCM or MTF. If not considered medically necessary, physical therapy services may be denied.
Please note that physical therapy exceeding 20 visits per episode of care requires a prior authorization for beneficiaries over age 21. Also, any combination of physical therapy and occupational therapy greater than 40 visits per episode for beneficiaries over age 21 also requires prior authorization.
Refer to the Referrals/Authorizations section of TriWest.com/Provider for more information about the referral and authorization process and available resources.
Sourcde: Tricare eNews; August 8, 2012