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This section will assist you with specific behavioral health aspects of the TRICARE program. ValueOptions—Humana Military’s behavioral health care partner—has provider relations representatives available to answer nonclinical questions, address concerns, or assist with requests for additional information. To reach a provider relations representative, call 1-800-700-8646 between 8 a.m. and 6 p.m. Eastern Time.
The behavioral health outpatient network consists of licensed providers, such as psychiatrists, psychologists, social workers, marriage and family therapists, certified psychiatric nurse specialists, licensed professional counselors (LPCs), licensed mental health counselors (LMHCs), and pastoral counselors.
If the provider is an LPC, an LMHC, or a pastoral counselor, a physician referral is required prior to the initial evaluation, which must be submitted with the initial claim, and oversight must continue throughout the course of therapy in order to be reimbursed by TRICARE. When filing claims electronically, evidence of oversight can be faxed to 1-803-462-3990. This is a statutory and regulatory TRICARE program requirement that cannot be altered or waived.
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If a behavioral health care referral is necessary, contact ValueOptions at 1-800-700-8646. A beneficiary may self-refer for care, and the network provider is responsible for securing any necessary authorizations. If the provider fails to obtain the authorization, claims payment may be denied and the beneficiary is held harmless.
Prior authorization requirements are listed below for each beneficiary category. In addition to these requirements, note that prior authorization is not required for emergency behavioral health inpatient admissions when referred by an evaluating physician (M.D. or D.O.). However, admissions resulting from a bona fide psychiatric emergency should be reported to ValueOptions within 24 hours of the admission or the next business day.
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Active duty service members (ADSMs) must receive behavioral health care services at an MTF when available. TRICARE Prime Remote (TPR) ADSMs can receive civilian behavioral health care with a prior authorization. All other ADSMs must have a referral from their (PCM) and prior authorization from ValueOptions to seek behavioral health care services from a civilian network or non-network provider.
They are not eligible for the initial eight self-referred visits.
Note: Prior authorization is not required for emergency behavioral health inpatient admissions when referred by an evaluating physician.
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TRICARE Prime beneficiaries will pay higher out-of-pocket, point-of-service (POS) costs if they self-refer to a non-network provider.
To ensure coordination of care, when a TRICARE Prime beneficiary is referred for behavioral health and/or substance use care, TRICARE requires the rendering provider submits a consult report to the PCM within 10 working days of the specialty encounter. Providers who treat TRICARE beneficiaries coming from the local MTF may receive a fax reminder to return a consult report for a recent visit or service. The office should return the consult report requested and use the designated fax reminder as the cover sheet. Please use the fax number shown in the center of the reminder page. This fax number is shown only on the fax reminder sent to the providers for each beneficiary consult report request. This is to avoid having providers send documentation on all other TRICARE beneficiaries. If the beneficiary refuses to sign a medical release for the consult report, the provider is obligated to inform ValueOptions of the beneficiary’s decision within the time period described above.
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