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Toll Free: 1-800-700-8646
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ValueOptions Home
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TRICARE Overview
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- Admissions: All inpatient admissions require authorization.
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- Contact ValueOptions: Call 1-800-700-8646 8 AM to 7 PM Eastern Time Monday through Friday except for federal holidays for information regarding behavioral health benefits, verification of patient eligibility, and authorizations.
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- PCM referral: A beneficiary does not need a Primary Care Manager (PCM) referral to access Mental Health services.
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- 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 and supervision with a physician. This physician does not have to be the beneficiaries PCM. The oversight does not have to be provided by the same physician who made the referral.
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- First 8 unmanaged outpatient visits: Beneficiaries receive 8 unmanaged outpatient visits each enrollment/fiscal year, which do not require authorization. However, Network Providers are encouraged to call for prior authorization for all outpatient behavioral health services. The following services are not included in the eight unmanaged 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 psychological testing (including neuropsychological testing);
5. All psychoanalysis; and
6. Electroconvulsive therapy.
Procedure codes 90808-9 and 90814-5 are defined as “crisis intervention” according to TRICARE policy. These codes require a separate authorization.
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- Outpatient Treatment Report: An Outpatient Treatment Report (OTR) is needed to authorize services beyond a beneficiary's initial 8 unmanaged visits. Network providers are asked to discuss PCM coordination of care with PRIME beneficiaries, and to indicate on the OTR form if release to the beneficiary's plan has been granted. Authorizations may be obtained by calling 1-800-700-8646 or by faxing an OTR to Valueoptions at 866-811-4422. 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.
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- 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.
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- Psychological Testing: A provider must request pre-authorization for psychological testing by submitting the psychological testing request form to ValueOptions' Utilization Management Department. A decision will be made within 3 working days of receipt of request. 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 HMHS.
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- 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.
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- 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.
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- 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.
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- 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.
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Submit paper claims to:
TRICARE South Behavioral Health
PO Box 7034
Camden, SC 29020-7034
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