Provider Handbook

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A psychiatric partial hospitalization program (PHP) provides an appropriate setting for crisis stabilization or treatment of partially stabilized behavioral health disorders and serves as a transition from an inpatient program when medically necessary.

All psychiatric PHPs must be TRICAREauthorized by the National Quality Monitoring Contractor (NQMC), Maximus, Inc. Providers may contact Maximus by the following means:
 

Additionally, psychiatric PHP facilities must be capable of providing an interdisciplinary program of medically therapeutic services at least three hours per day, up to five days per week, including day, evening, or weekend treatment.

PHP coverage details include:
 

• Prior authorization is required for all PHPs, without exception.
• PHP care is limited to a maximum of 60 treatment days (whether a full-day or half-day program) in a fiscal year (October 1–September 30) or for any single admission. The limit may be waived if the treatment is determined to be medically necessary.
• The 60 PHP treatment days are not offset by, nor counted toward, the inpatient limit of 30 days for beneficiaries age 19 years and older or 45 days for beneficiaries age 18 years and younger.

• Revenue Code 912—Psychiatric Partial Hospitalization, all-inclusive per diem payment of three to five hours (half-day)
• Revenue Code 913—Psychiatric Partial Hospitalization, all-inclusive per diem payment of six or more hours (full-day)

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Residential Treatment Centers (RTCs) provide treatment for children and adolescents (some centers provide treatment up to age 21) who require behavioral health care due to a serious behavioral health disorder. Children who only have disciplinary problems do not qualify for treatment in an RTC setting.

All RTCs must be TRICARE-authorized by the NQMC, Maximus, Inc., to provide residential treatment to TRICARE-eligible beneficiaries. Providers may contact Maximus by the following means:
 

A psychiatrist or other physician must recommend that the child be admitted to the RTC, and a psychiatrist or clinical psychologist must direct the development of a treatment plan. Documentation must be submitted to support each request, and the behavioral health disorder must meet clinical review criteria before admission can be authorized.

Additional RTC details include:
 

• RTC care is covered to a maximum of 150 days in a fiscal year or for a single admission, as medically necessary. These limits are subject to waiver in certain cases.
• Prior authorization is required.
• Concurrent review is conducted during the course of the RTC stay.

• Geographically distant family therapy—The family therapist may bill and be reimbursed separately from the RTC if the therapy is provided to one or both of the child’s parents residing a minimum of 250 miles from the RTC.
    
• RTC educational services—Educational services will be covered only in cases when appropriate education is not available from or not payable by local, state, or federal governments. TRICARE is always the payer of last resort. For network providers, this coverage limitation applies only if educational services are not part of the contracted per diem rate.
   
• Non-behavioral health services—Services provided to the beneficiary not related to behavioral health care, such as medical treatments for asthma or diabetes.

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