TRICARE covers detoxification, rehabilitation and outpatient care for treatment of alcohol or drug abuse disorders, as long as the care is medically necessary. The following is an overview of the outpatient rehabilitative services covered by TRICARE.
 

• Outpatient rehabilitative care is recommended for individuals who do not need detoxification and who are medically or psychologically stable. It is also helpful for patients who have been through rehabilitation in the past and just need additional support.
   
• A hospital-based setting is more appropriate for rehabilitation of patients who are unstable. A hospital-based rehabilitation program provides an interdisciplinary model for those with a medical or psychological condition. 

If your patients are not medically compromised, it may be appropriate to refer them to outpatient care at a freestanding substance abuse disorder rehabilitation facility.

Outpatient care for substance abuse must be provided by a TRICARE-authorized/certified substance abuse disorder rehabilitation facility, whether freestanding or hospital-based. Otherwise, beneficiaries will not be eligible for cost-sharing. Certified addiction rehabilitation counselors or certified alcohol counselors employed by the facility may provide the care.

TRICARE covers outpatient care for substance abuse rehabilitation in a group setting only. Beneficiaries are covered for up to 60 facility-based, group therapy visits per 365-day benefit period.

Patients needing rehabilitation, who also present with a coexisting mental health diagnosis (DSM-IV) like depression, can continue to seek individual therapy. In these cases, the treating therapist may submit claims using the mental health diagnosis as primary and the substance abuse diagnosis as secondary.

Family therapy is available as part of substance abuse rehabilitation. TRICARE allows 15 family therapy sessions for the substance abuse diagnosis.

Prior authorization is required for outpatient group therapy. Providers can fax in a treatment request.

For more information about substance abuse disorder treatment coverage, visit ValueOptions or call ValueOptions at
1-800-700-8646.
 

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Consult reports are required to be returned to the primary care manager or initiating provider within 10 working days of the patient encounter. For routine specialty referrals for initial office visits, all outpatient services and inpatient services, you must provide complete and legible documentation for these reports to be accurate and useful.

Returning consult reports, operative reports and discharge summaries to the initiating provider is important for timely follow up and continuity of care. Please be responsive to the request when asked to return a consult report for TRICARE beneficiaries.

Providers who treat TRICARE beneficiaries coming from the local military treatment facility may receive a faxed reminder to return a consult report for a recent visit/service. Your office should return the requested report and use the designated fax reminder as the cover sheet. Please use the fax number listed in the upper right corner of the reminder page.

This fax number is shown only on the reminder fax to providers for each beneficiary consult return request. This is to avoid having providers send documentation on all other TRICARE beneficiaries.

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Last Reviewed:  February 1, 2007