The following services and coverage guidelines are based on TRICARE policy.
Claims: Network providers must file TRICARE beneficiary claims, even when the beneficiary has other health insurance (OHI). Only physicians and other providers licensed or certified as behavioral health clinicians may bill for psychiatric CPT codes or DSM-5 diagnoses. Behavioral health includes the ICD-10 diagnosis range: F01.50-F99.
Inpatient treatment: All inpatient admissions require authorization. Use self-service for providers to submit the required information.
Non-covered services: All non-covered services must be agreed to in advance, in writing, on a Humana-approved form for the beneficiary to be liable for the payment. A written waiver must be obtained for each non-covered service rendered. If the waiver is not obtained in advance, the beneficiary cannot be held responsible for cost of the service. A general waiver does not meet this requirement.
Outpatient treatment: Active Duty Service Members require MTF referral for all behavioral health services. Active Duty Family members, Retirees and their families and others receive eight outpatient visits each fiscal year that do not require a referral or authorization. Visits nine and beyond require authorization, and a referral is never required. Services are limited to therapy no more than two times per week (when medically necessary).
Network providers are encouraged to obtain prior authorization for all outpatient behavioral health services. An outpatient treatment report (OTR) is needed to authorize services beyond a beneficiary's initial eight visits per fiscal year. Network providers should discuss PCM coordination of care with TRICARE Prime beneficiaries. Use self-service for providers to submit the required information.
With the exception of ABA services, authorizations may be requested by visiting the self-service for providers portal. Care that is reviewed retrospectively will result in up to a 50% penalty to the provider. The cost will be borne by the provider, and the beneficiary will be held harmless.
The following services are not included in the eight initial visits and always require prior authorization:
Psychological testing: Six units per fiscal year are covered without an authorization. Providers needing more than six units are encouraged to submit their request for additional units via the self-service for providers portal.
Educational testing, vocational testing, testing based only on court order, and testing based only on a child custody case are excluded. Requests for testing to rule out a medical condition should be directed to Humana Military.
Referrals: TRICARE-eligible beneficiaries (except Active Duty Service Members) do not need a Primary Care Manager (PCM) referral to access mental health services, except when services are provided by a Supervised Mental Health Counselor or Pastoral Counselor. For Applied Behavior Analysis services, referrals are required.
Self-service: For benefit information, patient eligibility verification, authorization requests and claims status, visit self-service for providers
ValueOptions: ValueOptions Federal Services, Inc. is the behavioral health subcontractor for Humana Government Business (HGB), the Managed Care Support Contractor (MCSC) authorized by the TRICARE Program to review requests for coverage of healthcare services in the TRICARE Program in the South Region.
Provider relations representatives are available 8 a.m. to 6 p.m. Eastern time, Monday through Friday, excluding federal holidays. Send an email to ProvHelpTricare@jax.valueoptions.com or call 1-800-700-8646.