Your pregnant patients have enough to think about, and TRICARE coverage of their obstetric care shouldn’t be one of their concerns. The TRICARE Prime Global Maternity Benefit makes pregnancy coverage easy to understand and manage.

If the beneficiary has TRICARE Prime and you are not going to manage the care during her pregnancy, a referral is required to the obstetrician (OB) to confirm the pregnancy and cover prenatal and postnatal office visits. The referral covers an initial visit and all subsequent routine maternity care visits as long as the date of service is prior to the referral expiration date. Non-related maternity care within the OB provider’s office during pregnancy is allowed without another referral from the primary care manager (PCM).

An inpatient authorization is required for the delivery for beneficiaries with TRICARE Prime or TRICARE Standard benefits. This authorization covers the facility charge and all professional charges associated with the delivery.

For any other pregnancy-related inpatient admission or services other than delivery, a separate referral or admission authorization is required. An example of this type of situation would be a maternity patient presenting to the emergency room with a broken arm: a separate referral from her PCM for follow-up care with an orthopedic provider would be required.

Although it is not required, if Humana Military is notified of an observation stay, the referral will be entered.

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Keeping patients on the path to recovery is the goal of every behavioral health provider, and one of the tools used to keep that path as straight as possible is the peer-review process.

Through the peer-review process, Humana Military’s behavioral health partner ValueOptions gives you, the provider, an opportunity to have others look at your work and provide feedback that can help your patients. Peer reviews are used when additional clinical information is required to support medical necessity for the continuation of outpatient care. Peer reviews help determine if a patient is making progress and the treatment they are receiving is appropriate and meeting their needs. It also ensures a patient’s benefits are being utilized properly.

During the past two years, approximately five to 10 cases per week have been referred to the peer-review process. ValueOptions uses licensed professional social workers, marriage and family therapists, nurses, psychologists and physicians in the peer-review process. Peer reviews are done by staff with similar licensure, whose goal is to ensure that beneficiaries receive care that is individualized and goal-oriented. This allows both providers and beneficiaries to determine how they are progressing and where they need to focus additional attention.

It’s imperative in a cost-driven economy to remember that as a provider, you are guiding a patient’s treatment. Therapy should address an individual patient’s behavioral health needs so he or she can apply the skills they learn to everyday life experiences. Even chronic patients need the opportunity to put new coping skills into practice to better manage their lives—with a variety of support systems that you can help facilitate.

“The goal of any therapy is to give the beneficiary tools to cope with their current stressors and get them back on their feet,” said Debbie Del Rosario, outpatient supervisor with ValueOptions. “Granted, some may need continuing care, but we want to make sure they’re making progress in their treatment goals.”

If you have questions regarding the peer review process, you may contact ValueOptions at 1-800-700-8646.

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Updated: August 6, 2007