Provider Handbook - Behavioral Health-Appeals and Reconsiderations

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Behavioral Health Services Referrals & Authorizations Referral & Authorizations by Category Provider Responsibilities Outpatient Services Inpatient Services Partial Hospitalization Programs Residential Treatment Centers Substance Use Disorders Court Ordered Care Non-Covered Services Management Appeals & Reconsiderations Medical Record Documentation Billing and Claims Coverage Details

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Appeals and Reconsiderations

If behavioral health care services have been denied, beneficiaries and non-network providers may request a reconsideration by submitting a written request, a copy of the denial letter, and documentation that supports the clinical rationale for their treatment decisions. Beneficiaries may appoint the provider or another representative to represent them as the appealing party. A copy of the necessary components of the medical record must be submitted with the written request to:

ValueOptions
Attn: Appeals and
Reconsideration Department
P.O. Box 551138
Jacksonville, FL 32255-1138

Providers and beneficiaries will be notified, in writing, of the reconsideration decision within 30 days of the date of the receipt of the reconsideration request (within three working days for expedited requests). If the initial denial determination is upheld, the provider and beneficiary will be notified, in writing, of the process to request a second reconsideration.

Proper appealing parties for medical necessity include:

A TRICARE beneficiary (including minors)
A TRICARE-authorized (non-network) provider of services
Any party appointed by the beneficiary

If the proper appealing party cannot or does not wish to pursue the appeal personally or wishes to have another person directly assist in pursuing an appeal, the appealing party can appoint a representative to act on his or her behalf at any level of the appeal process. The appointment of a representative must be in writing and must be signed by the proper appealing party, or an individual can be appointed to act as a representative by a court of competent jurisdiction. Appeals must be submitted in writing to ValueOptions.

Incident Reporting Requirements

Any serious occurrence involving a TRICARE beneficiary while receiving services at a TRICARE-authorized treatment program (RTC, PHP facility, or freestanding SUDRF) must be reported to ValueOptions and the NQMC within one business day. Reportable occurrences are defined by TRICARE as follows: a life-threatening accident, a patient death, a patient elopement, a suicide attempt, cruel or abusive treatment, physical or sexual abuse, or any equally dangerous situation. TRICARE participation agreements outline specific requirements.

The point of contact for TRICARE incident reporting is Maximus. Review of serious incidents is included as a facility certification function. The address for Maximus is:

NQMC—Maximus
1600 E. Northern Ave.
Suite 100
Phoenix, AZ 85020

Last Update: August 26, 2009