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Provider Handbook
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Appeals and Reconsiderations
Incident Reporting Requirements
Behavioral Health Medical Record Documentation |
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Appeals and Reconsiderations
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If behavioral health services have been denied, beneficiaries and non-network providers may request a reconsideration by submitting a written request, a copy of the denial letter, and documentation that supports the clinical rationale for their treatment decisions. Beneficiaries may appoint the provider or another representative to represent them as the appealing party. A copy of the necessary components of the medical record must be submitted with the written request to:
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ValueOptions Behavioral Health
Attn: Appeals and Reconsideration
Department
P.O. Box 551138
Jacksonville, FL 32255-1138
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Providers and beneficiaries will be notified, in writing, of the reconsideration decision within 30 days of the date of the receipt of the reconsideration request (within three working days for expedited requests). If the initial denial determination is upheld, the provider will be notified, in writing, of the process to request a second reconsideration.
Proper appealing parties for medical necessity include:
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- A TRICARE beneficiary (including minors)
- A TRICARE-authorized (non-network) provider of services
- Any party appointed by the beneficiary
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If the proper appealing party cannot or does not wish to pursue the appeal personally or wishes to have another person directly assist in pursuing an appeal, the appealing party can appoint a representative to act on his or her behalf at any level of the appeal process. The appointment of a representative must be in writing and must be signed by the proper appealing party, or an individual can be appointed to act as a representative by a court of competent jurisdiction. Appeals must be submitted, in writing, to ValueOptions. |
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Incident Reporting Requirements |
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Any serious occurrence involving a TRICARE beneficiary while receiving services at a TRICARE-authorized treatment program ( RTC, PHP facility, or freestanding SUDRF) must be reported to ValueOptions and the NQMC within one business day. 123 Reportable occurrences are defined by TRICARE as follows: a life-threatening accident, a patient death, a patient elopement, a suicide attempt, cruel or abusive treatment, physical or sexual abuse, or any equally dangerous situation. TRICARE participation agreements outline specific requirements.
The point of contact for TRICARE incident reporting is Maximus, Inc. Review of serious incidents is included as a facility certification function. The address for Maximus is:
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NQMC—Maximus
1600 E. Northern Ave.
Suite 100
Phoenix, AZ 85020
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Behavioral Health Medical Record Documentation |
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The following information should be included in each individual beneficiary record. The credentials or provider type for each provider represented in the record should appear each time.
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- Beneficiary identification (name and identification number) on each page
- Allergies
- Date and time of visit
- Chief complaint or problem
- History of problem
- Physical assessment
- Diagnosis/impression
- Appropriate discharge planning
- Treatment plan goals
- Legible provider name(s) and signature(s)
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