Provider Handbook - Behavioral Health-Inpatient Services

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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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Inpatient Services

Inpatient Psychotherapy

Inpatient psychotherapy is limited to five sessions of any kind of psychotherapy per calendar week (Sunday–Saturday), unless medical review of the overall treatment plan for medical necessity and appropriateness is conducted.

Note: Facilities with all-inclusive contracts that include psychotherapy will not receive a separate payment for inpatient psychotherapy.

All facilities, whether hospital-based or freestanding, must adhere to the balance billing, release of medical records, and waiver of non-covered services provisions outlined in “Provider Responsibilities” earlier in this section.

Acute Inpatient Care

The purpose of acute inpatient care is to stabilize a life-threatening or severely disabling behavioral health condition. TRICARE defines a psychiatric emergency admission as “an admission when, based on a psychiatric evaluation performed by a physician (or other qualified behavioral health care provider with hospital admission authority), the beneficiary is at immediate risk of serious harm to self or others as a result of a behavioral health disorder and requires immediate continuous skilled observation at the acute level of care.”

In a life-threatening situation, the provider should direct the beneficiary to the closest appropriate health care facility or emergency room. If an MTF is geographically available, referral to the MTF emergency room is an available option. The beneficiary’s age at the time of admission determines the actual number of benefit days per fiscal year (October 1–September 30) that can be authorized for acute inpatient care. The limits are as follows:

Up to 30 days for beneficiaries age 19 and older
Up to 45 days for beneficiaries age 18 and younger

An inpatient admission for substance use detoxification and rehabilitation counts toward the 30- or 45-day limit for inpatient behavioral health care services, regardless of whether the beneficiary is admitted to a general hospital or freestanding substance use disorder rehabilitation facility (SUDRF).

Prior authorization is required for all nonemergency admissions. Admissions resulting from a bona fide psychiatric emergency should be reported within 24 hours of the admission or the next business day after the admission. ValueOptions will conduct a concurrent review for continuation of inpatient behavioral health care services and authorize additional days, as appropriate, based upon medical necessity.

Last Update: August 26, 2009