Provider Handbook - Behavioral Health-Inpatient Services

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Behavioral Health Services Providers Referrals & Authorizations Obtaining Referrals/Authorizations Accessing Care Programs Offered Outpatient Services Inpatient Services Residential Treatment Centers Substance Use Disorder Services Court Ordered Care Management Appeals & Reconsiderations Medical Record Documentation Billing and Claims Non-Covered Services

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Inpatient Services

All non-emergency admissions require prior authorization from ValueOptions. A non-TRICARE Prime beneficiary may also have to obtain an NAS before receiving non-emergency inpatient care.

Acute Inpatient Psychiatric Care

The beneficiary’s age at the time of admission determines coverage limits. Stay limits may be waived if medically or psychologically necessary. The following limits apply:

Patients age 19 and older: 30 days per FY or in any single admission
Patients age 18 and under: 45 days per FY or in any single admission

Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30- or 45-day limit. ValueOptions may approve additional days, as appropriate, based on medical necessity.

Partial Hospitalization Program Care

Psychiatric PHPs provide interdisciplinary therapeutic services at least three hours a day, five days a week, in any combination of day, evening, night, and weekend treatment programs. A full-day program lasts at least six hours, and a half-day program lasts between three and five hours. PHPs employ an integrated, comprehensive, and complementary schedule of recognized treatment approaches. PHP care is appropriate for crisis stabilization, treatment of partially stabilized mental health disorders, or transitioning a patient from an inpatient program when medically necessary.

A TRICARE-authorized psychiatric PHP can be either a distinct part of an otherwise TRICARE-authorized institutional provider or a freestanding program:

Hospital-based PHP: Effective November 30, 2009, a hospital-based PHP no longer needs separate TRICARE certification from the TRICARE Quality Monitoring Contractor (TQMC). A PHP that is part of a TRICARE-authorized hospital is also considered TRICARE-authorized.
Freestanding PHP: A freestanding PHP must be TRICARE-certified by the TQMC and must enter into a participation agreement with TRICARE. See the Important Provider Information section of this handbook for more information.

A psychiatrist employed by the PHP must provide general direction to ensure treatment meets both pharmaceutical and physical needs. A primary or attending TRICARE-authorized behavioral health care provider may only provide care that is part of the PHP treatment plan.

The following coverage limitations apply:

PHP care is considered elective (nonemergency) and always requires referral and prior authorization from ValueOptions.
PHP care is limited to a maximum of 60 treatment days (full- or half-day program) per FY or for any single admission. Note: PHP care for substance use disorders is limited to 21 days ( full- or half-day program) per FY or for any single admission.
The 60 PHP treatment days are not offset by, nor counted toward, the 30- or 45-day behavioral health care inpatient limit.

Partial Hospitalization Program Claims

TRICARE reimburses outpatient service claims, including claims for hospital-based PHPs (psychiatric and SUDRFs) subject to TRICARE prior authorization requirements, based on the national per diem Ambulatory Payment Classification (APC) payment methodology under the outpatient prospective payment system (OPPS). The OPPS is mandatory for both network and non-network providers. TRICARE follows Medicare’s reimbursement methodology, which uses two separate APC payment rates, to reimburse hospital-based PHP claims:

APC 0172: For days with three services
APC 0173: For days with four or more services

When billing hospital-based PHP care under OPPS, list the appropriate Healthcare Common Procedure Coding System (HCPCS) and revenue codes separately for each service date. Report PHP services under bill type 013X and with condition code 41 on a UB-04 claim form. The claim must also include a behavioral health primary diagnosis and an authorization for each service date.

TRICARE continues to reimburse freestanding PHP claims under the current per diem rate schedule. The per diem rate includes the provider’s overhead costs, support staff, and clinical social worker and occupational therapist professional services. The SUDRF per diem rate includes alcohol and addiction counselor services. Bill PHP care on UB-04 forms and use the following codes:

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

Note: Individual TRICARE-authorized behavioral health care providers may bill separately for certain professional services.

For more information about PHPs, refer to the TRICARE Reimbursement Manual, Chapter 7, Section 2 at TRICARE Manuals Online. To learn more about OPPS, refer to the TRICARE Reimbursement Methodologies section of this handbook or the TRICARE Reimbursement Manual, Chapter 13, Section 2 or call ValueOptions at 1-800-700-8646.

Last Update: April 06, 2011