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TRICARE East ECT Prior Authorization Request Form

Humana Military requires prior authorization for electroconvulsive therapy for TRICARE East beneficiaries, and this nine-page form covers four request types: inpatient ECT, outpatient acute ECT, outpatient maintenance ECT, and extension of an existing inpatient or outpatient authorization. Each section asks for diagnoses, medication history, prior psychotherapy and ECT, the CPT 90870 units and frequency, and medical clearance.

Who completes it

The treating psychiatrist or ECT provider completes the beneficiary, facility, rendering and ordering provider pages, then only the section for the request type, and signs it.

Submitting and payment

How to submit it
Type it in the fillable fields rather than by hand and submit it through Humana Military provider self-service; fax only if online submission is not possible.
Who pays
Treatments are requested under CPT 90870 with the number of units and frequency, alongside the anticipated start and completion dates.

Good to know

  • Inpatient and acute outpatient sections ask whether medical review and clearance were completed before ECT and whether treatment will proceed only if the patient is medically cleared.
  • Maintenance requests must show adjunctive pharmacotherapy was optimized or not tolerated, and that sessions will be tapered to the lowest frequency that maintains response.
  • Extension requests need the existing authorization number, any diagnosis or medication changes, and a clinical summary of treatment response and how treatment is being modified.
  • The signature attests the beneficiary is physically and intellectually capable of taking part in the program. Current version XPAF0126-A, January 2026.

Get the official form

Download the current version from the source each time; forms change without notice.

Electroconvulsive Therapy (ECT) treatment request

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does TRICARE require prior authorization for ECT?

In the East Region, Humana Military uses this prior authorization form for inpatient, outpatient acute and outpatient maintenance ECT, and for extensions of an existing authorization. The form says to complete it with the fillable fields and submit it through provider self-service to avoid delays or denials.

What does Humana Military need for maintenance ECT?

Section III asks for changes to diagnosis or medications since the episode began, a clinical progress summary showing why maintenance is needed to reduce relapse risk, confirmation that pharmacotherapy was optimized or not tolerated, a plan to taper to the lowest effective frequency, and medical clearance.

How is a TRICARE ECT authorization extended?

Use Section IV with the current authorization number. It asks for any diagnosis or medication changes, a clinical summary supporting continued acute treatment including response and adjustments, the CPT 90870 units and frequency, and whether there are contraindications to continuing ECT.