Provider Handbook

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The provider shall request each beneficiary sign a release of information, to include all ancillary services, in order to release medical information. The records of beneficiaries should be maintained in accordance with all state and federal regulations. Providers are allowed under the Health Insurance Portability and Accountability Act (HIPAA) to release information regarding treatment, payment, and operations to ValueOptions without the beneficiary’s authorization. This includes record requests for validation audits conducted by the National Quality Monitoring Contractor (NQMC), Maximus, Inc., as well as ValueOptions Quality and Utilization Management activities.

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Waiver of Non-covered Services

A network provider can utilize the waiver of non-covered services when the beneficiary is properly informed, in advance, that TRICARE does not cover a particular service and he or she agrees in writing to be financially responsible. TRICARE beneficiaries must be properly informed in advance and in writing of specific services or procedures that are not covered under TRICARE before they are provided. However, if the provider does not obtain a legal signed waiver, and the care is not authorized, the provider is expected to accept full financial liability for the cost of the care.

For the beneficiary to be considered fully informed, TRICARE regulations require that:
 

• The agreement is documented prior to the specific non-covered services being rendered.
• The agreement is in writing.
• The specific treatment, rendering provider, cost of services, and date(s) of service are documented.
• General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or not allowable.
• Providers should maintain copies of the waiver in their office and fully inform beneficiaries in advance when specific services or procedures are not covered.

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A nonavailability statement (NAS) is required for all nonemergency behavioral health admissions. An NAS is a certification from an MTF stating that it cannot provide a specific required service at a particular time to a non-enrolled (i.e., non- TRICARE Prime) beneficiary residing within the MTF catchment area.

Providers should advise TRICARE beneficiaries to check with the beneficiary counseling and assistance coordinator (BCAC) at the local MTF to find out if an NAS is required before obtaining non-emergency behavioral health inpatient services. An NAS does not take the place of an authorization for those services requiring prior authorization.

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