Provider Handbook

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• Crisis intervention
• ECHO services authorized by Humana Military
• ECT
• Nonemergency inpatient admissions for substance use disorder or behavioral health services
• Partial hospitalization programs
• Psychoanalysis
• Residential treatment center programs
• Psychological/neuropsychological testing

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Beneficiaries using Medicare as their primary payer are not required to obtain referrals or prior authorization from ValueOptions for inpatient or outpatient behavioral health care services. These beneficiaries should follow Medicare rules for services requiring authorization.   They may self-refer to any network or non-network provider. When behavioral health benefits are exhausted under Medicare, TRICARE becomes the primary payer, and prior authorization from ValueOptions is then required.

Note : If the provider’s licensure level is recognized by Medicare, the provider must be Medicare certified.  If a provider’s licensure level is not recognized by Medicare (such as If a provider’s licensure level is not recognized by Medicare (such as LMHC,  LMFT, LPC), TRICARE becomes primary payer and TRICARE Standard cost shares and deductibles apply, unless the beneficiary is an active duty family member (ADFM).

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• Wait time for specialty care appointments will be based on the nature of the care required, but will not exceed four weeks. Behavioral health care is considered a specialty. The  PCM determines the level of urgency.
  
  
• Office waiting times for nonemergency situations will not exceed 30 minutes.  Providers who are not able to adhere should notify the patient and offer to reschedule.

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Network providers may only bill TRICARE beneficiaries for applicable deductible, copayment, or cost-share amounts, but may not bill for charges that exceed contractually allowed payment rates. Because network providers have contractually agreed to adhere to these provisions, TRICARE beneficiaries will be referred first to a network provider.

Non-network providers who do accept assignment (participating providers) are limited to collecting the TRICARE allowable charge. If the billed charge is less than the allowable charge, the billed charge becomes the allowable charge. This only applies to services covered by TRICARE.

When providers do not accept assignment on a claim, non-network providers may collect applicable deductibles and/or cost-shares and any outstanding amounts up to 15 percent above the TRICARE allowable charge (shown on the remittance advice) from a TRICARE beneficiary. If the billed charge is less than the TRICARE allowable charge, the billed charge becomes the billable amount to the beneficiary. TRICARE discourages military families from using non-network non-participating providers.

This applies only to services covered by TRICARE. TRICARE’s balance-billing limit also applies when other health insurance (OHI) is involved. Providers are limited to collecting the amount described previously. Generally, the OHI payment, when combined with TRICARE’s payment, represents the total amount a provider can bill.

Non-compliance with these balance-billing requirements by any TRICARE provider may affect that provider’s TRICARE and/or Medicare status. Visit the TRICARE Web site for additional information on this topic.

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