As a behavioral health care provider, you have an important responsibility to meet the emotional and behavioral health care needs of your TRICARE patients. Here are some helpful reminders to follow when billing and submitting authorization requests to ensure proper coverage for your patients and timely reimbursement for your services.

When Is a Crisis Really a Crisis?

You may be familiar with a variety of procedure codes. However, it is especially important to know the guidelines for billing crisis intervention, which TRICARE policy defines as [Physician’s] Current Procedural Terminology (CPT) codes 90808, 90809, 90814 and 90815.

Crisis intervention involves a 75 to 80 minute face-to-face session in an outpatient setting. These sessions must be medically necessary and authorized. Further information can be found in the TRICARE Policy Manual Chapter 7 Section 3.13 Psychotherapy and in the TRICARE Provider Handbook.

Crisis intervention procedure codes should only be used when there is a clinical need for the intervention and not when a routine therapy session has failed to terminate timely. Not all sessions are a crisis; therefore, authorization is required to determine medical necessity.

To obtain authorization for outpatient crisis intervention, you must supply clinical justification defining the crisis to ValueOptions, Humana Military’s subcontractor for behavioral health. You can fax your request in writing to 1-866-811-4422 or call ValueOptions at 1-800-700-8646 and ask to speak with a clinician.

Outpatient Treatment Reports

When ValueOptions receives your outpatient treatment report (OTR), a clinician reviews and approves units based on medical necessity. If units are approved, an autofax is sent to your office notifying you of the number of units approved and an expiration date for the services.

ValueOptions has noticed an increase in OTR requests when an adequate number of unused units are still available. It is important to remember to thoroughly read the information that is autofaxed to you regarding your authorizations for continued care and note this information in the patient’s chart. This will prevent unnecessary paperwork for your office staff.

In addition to crisis intervention treatment, all inpatient behavioral health services require authorization. Specifically, higher levels of care (HLOC) require prior authorization, such as those provided in a Partial Hospitalization Program (PHP) or a Residential Treatment Center (RTC), which requires the submission of a full and complete RTC application form.

It is important to inform your patient that while these types of treatment may be recommended, they are not considered an emergent level of care and may therefore require a few days to obtain prior authorization. ValueOptions generally processes authorization requests within two business days, and all requests are processed within five business days following receipt of the request and all required information.

Therefore, be sure that you allow sufficient lead-time when you submit your prior authorization requests to ensure that ValueOptions has the opportunity to properly review and authorize the care if deemed medically necessary. Failure to obtain prior authorization or submit your requests in a timely manner could result in disappointed patients, uncovered days or late penalties.

If your patient is admitted after business hours on Friday, over the weekend or on a holiday, fax the TRICARE Higher Level of Care Treatment Report form to ValueOptions promptly to avoid potential late notification penalties. Forward the HLOC form to ValueOptions within 24 hours of the admission. The request will be distributed to clinicians and reviewed early on the next business day for a medical necessity determination.

Back to Top

Last Reviewed:  February 13, 2007