• Admissions:    All inpatient admissions require authorization. Fax a Higher Level of Care form to 1-866-811-4422
   
• Contact ValueOptions:  For benefit information, patient eligibility verification, authorization requests and claim status visit the MyHMHS Secure Services portal. Associates are available at 1-800-700-8646 Monday-Friday 8AM-7PM, excluding federal holidays.
    
• PCM referral: All TRICARE eligible beneficiaries (except Active Duty Service Members) do not need a Primary Care Manager (PCM) referral to access Mental Health services.
   
• LPC, LMHC, and Pastoral Counselors: TRICARE policy requires LPCs, LMHCs, and Pastoral Counselors to have a written referral with diagnosis from a physician. They must also have ongoing communication with the referring physician. This physician does not have to be the beneficiary’s PCM.
   
• First 8 initial outpatient visits per fiscal year: Beneficiaries receive 8 outpatient visits each fiscal year, which do not require authorization. However, Network Providers are encouraged to obtain prior authorization for all outpatient behavioral health services. The following services are not included in the eight initial visits and always require prior authorization:

1. All substance abuse treatment (inpatient or outpatient);
2. All inpatient levels of care, including care rendered by residential treatment centers;
3. All partial hospitalization levels of care;
4. All psychoanalysis; and
5. Electroconvulsive therapy.

 Outpatient Treatment Report:  An Outpatient Treatment Report (OTR) is needed to authorize services beyond a beneficiary's initial 8 visits each fiscal year. Network providers are asked to discuss PCM coordination of care with PRIME beneficiaries. Authorizations may be obtained by visiting the MyHMHS Secure portal. Care that is reviewed retrospectively will result in up to a 50% penalty to the provider. The cost will be borne by the provider and the beneficiary will be held harmless. 

• Outpatient Services: are limited to one hour of therapy no more than two times per week (when medically necessary). More than two sessions per week may be authorized if determined to be medically necessary.
   
• Psychological Testing: Six units per fiscal year are covered without an authorization. Providers needing more than six units are encouraged to submit their request for additional units via the MyHMHS Secure portal. Educational testing, vocational testing, testing based only on court order, and testing based only on a child custody case are excluded. Requests for testing to rule out a medical condition should be directed to Humana Military.
   
• Military Treatment Facilities: ValueOptions is responsible for ensuring that Mental  Health and Substance Abuse services are maximized when space is available at Military Treatment Facilities (MTF) prior to coordinating referrals to civilian providers and facilities.
   
• Signed Release:  Mental Health providers who see PRIME beneficiaries must obtain a signed release of information from the beneficiary or guardian prior to releasing information to the member's PCM. If the beneficiary refuses to authorize the release of information, the information will not be released.
   
• Non covered services: must be agreed to in advance in writing on a ValueOptions approved form for the beneficiary to be liable for the payment. A written waiver must be obtained for each non-covered service rendered. If the waiver is not obtained in advance, the beneficiary cannot be held responsible for cost of the service. A general waiver does not meet this requirement.
   
• Claims:  Network providers must file TRICARE beneficiary claims, even when the beneficiary has Other Health Insurance (OHI). Only physicians and other providers licensed or certified as behavioral health clinicians may bill for psychiatric CPT codes or DSM-IV diagnoses. Behavioral health includes the ICD-9 diagnosis range: 290.0 – 314.9.