When you provide behavioral health care services to a TRICARE beneficiary, there are a few things to remember to ensure your patient receives the best quality care, and you receive timely payment for your services.

Active duty service members (ADSMs) typically receive their behavioral health care from a military treatment facility (MTF) and the service member’s command must approve all behavioral health care before it is provided. If services are not available at the MTF or if ADSMs are not located near an MTF, the ADSMs must have a referral from their primary care manager (PCM) and prior authorization from ValueOptions to seek any behavioral health care services from a civilian network or non-network provider.

All non-active duty TRICARE beneficiaries can receive the first eight outpatient visits per fiscal year without a referral from their PCM or an authorization from ValueOptions. Please keep in mind the initial eight visits are given per beneficiary per fiscal year and not per provider. TRICARE Prime and TRICARE Prime Remote beneficiaries must seek their initial visits from a network provider.

A physician (i.e., M.D. or D.O.) referral is necessary when beneficiaries seek care from a licensed professional counselor, licensed mental health counselor or a pastoral counselor. TRICARE requires a physician referral prior to the initial evaluation. Oversight by a physician must continue throughout the course of therapy in order to be reimbursed by TRICARE. TRICARE policy states that providers must keep the referral in the beneficiary’s record and must indicate this information on the claim form.

Once the initial eight unmanaged visits have been exhausted, a prior authorization for continued care is required. Additionally, the following behavioral health services are not included as part of the initial eight unmanaged visits and always require prior authorization, even if the beneficiary has other health insurance:
 

• Crisis intervention
• Extended Care Health Option services
• New and evolving technology
• Non-network provider services
• Partial hospitalization
• Psychoanalysis
• Substance abuse treatment
• Residential treatment
• Electroconvulsive therapy

  
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Doctors in military treatment facilities (MTFs) are often faced with consultation reports missing from the medical records when patients return for care. We all know the frustration and adverse impact on patient care caused by missing records. For many reasons, this has been particularly problematic for military medicine.

Returning consultation reports, operative reports and discharge summaries to the initiating provider is important for timely follow-up and continuity of care. For active duty service members who are awaiting deployment or transfer, missing records can even harm military readiness.

Faxes from Humana Military, which authorize care, instruct specialists to fax reports to a centralized number. The report is then delivered to MTFs electronically.

Please be responsive in returning consultation and other reports for TRICARE beneficiaries. Though we are seeing an improvement, MTFs in the TRICARE South Region currently receive consultation reports from civilian providers within 30 days for only 70 to 75 percent of referrals.
We have room for improvement and need your help.

Providers who treat TRICARE beneficiaries from the local MTF may receive a faxed reminder to return a consult report for a recent visit.

Your office should return the requested report, using the Humana Military reminder as a fax cover sheet. Just as in civilian practice, specialists who communicate well with referring doctors may become preferred sources of care in future referrals.

Please contact your Humana Military Provider Relations Representative if you have questions or suggestions about our program to facilitate return of consultation reports to referring doctors. Call 1-800-444-5445 if you do not know your Provider Relations Representative’s number.

Thank you for your assistance and for participating in TRICARE.

  
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Updated: April 7, 2008