Link to an amendment published at 89 FR 34137, Apr. 30, 2024.

Preauthorization or advance approval is required for any of the following, except when the benefit is covered by the CHAMPVA beneficiary's other health insurance (OHI):

(a) Non-emergent inpatient mental health and substance abuse care including admission of emotionally disturbed children and adolescents to residential treatment centers.

(b) All admissions to a partial hospitalization program (including alcohol rehabilitation).

(c) Outpatient mental health visits in excess of 23 per calendar year and/or more than two (2) sessions per week.

(d) Dental care. For limitations on dental care, see § 17.272(a)(21)(i) through (xii).

(e) Organ transplants.

(e) Organ transplants.

(f) CHAMPVA will perform a retrospective medical necessity review during the coordination of benefits process if:

(1) It is determined that CHAMPVA is the responsible payer for services and supplies but CHAMPVA preauthorization was not obtained prior to delivery of the services or supplies; and,

(2) The claim for payment is filed within the appropriate one-year period.

[63 FR 48102, Sept. 9, 1998, as amended at 74 FR 31374, July 1, 2009; 87 FR 41601, July 13, 2022]