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):

1. (a) Non-emergent inpatient mental health and substance abuse care including admission of emotionally disturbed children and adolescents to residential treatment centers.
2. (b) All admissions to a partial hospitalization program (including alcohol rehabilitation).
3. (c) Outpatient mental health visits in excess of 23 per calendar year and/or more than two (2) sessions per week.
4. (d) Dental care. For limitations on dental care, see § 17.272(a)(21)(i) through (xii).
5. (e) Organ transplants.
6. (e) Organ transplants.

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

   1. (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. (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]