Many TRICARE providers have participated in peer review processes. Peer review provides the opportunity to have others look at your work and provide constructive feedback. It also helps ensure that patients are progressing and that treatment is appropriate.

Although most providers “start where the client is,” it is imperative in this cost-driven economy to remember that you as the provider are also “guiding treatment.” That means looking at individual needs and addressing issues so that behavioral health care patients can draw on the skills they learn and carry them over into their everyday lives. It does not mean that treatment is indefinite. Even chronic patients need to have the opportunity to put newly learned coping skills into practice and to manage in their communities with a variety of support systems that you can help facilitate.

Since the transition to the new TRICARE South Region, ValueOptions’ Utilization Management Department has implemented a peer review process for behavioral health care providers. The process gives you the opportunity for clinical peer review when requested care may potentially be denied. It is important to understand that peer review affects only a small percentage of authorization requests.

How Peer Review Works
Peer review is handled by the Utilization Management Department, which is made up of licensed professional social workers, marriage and family therapists, nurses and psychologists. Peer reviews are done by “like licensure” staff whose goal is to ensure that beneficiaries receive care that is individualized and goal-oriented. This allows both providers and beneficiaries to determine how they are progressing and where they need to focus additional attention.

The ValueOptions peer reviewer will review requests for ongoing treatment and make decisions based on “best clinical practices” for the diagnosis, as well as individual clinical necessity. If adequate information is not available to make this determination, the reviewer will contact the provider by phone. The reviewer will ask for a written summary detailing why the beneficiary needs continued treatment, the goals of this treatment and an anticipated discharge date.

If the reviewer determines, after reviewing all clinical information, that the treatment meets clinical necessity, ValueOptions will fax an authorization in the usual manner. If requested services are denied, a letter will be mailed to you and the beneficiary that explains the appeals process.

Of course, if a beneficiary’s condition should change and you deem treatment to be indicated (even though a previous authorization request was denied), you should resubmit the request, noting the new circumstances. ValueOptions will consider these new developments in any subsequent treatment reviews.

If you have questions about peer reviews or utilization management, you can e-mail ValueOptions at provhelptricare@valueoptions.com or call your provider representative at 1-800-700-8646.

Consult Reports are Required within 10 Working Days (Article 5)

Consult reports are required to be returned to the primary care manager (PCM) or initiating provider within 10 working days of the patient encounter. For these reports to be accurate and useful, you must provide complete and legible documentation.

Consult reports, “op” reports and discharge summaries returned to the initiating provider are important for timely follow-up and continuity of care, so please be responsive when asked to return a consult report for TRICARE beneficiaries.

Providers who treat TRICARE beneficiaries referred from a local military treatment facility (MTF) may receive a faxed reminder to return a consult report for a recent visit or service. Your office should return the consult report, “op” report or discharge summary requested and use the designated fax reminder page as the cover sheet. Please use only the fax number listed in the upper right corner of the reminder page.

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