Utilization management for behavioral health care is a process that manages the beneficiary at the point of care through prospective review, concurrent review, retrospective review, case management, discharge planning, and aftercare planning activities.
Prospective Review
A prospective review is a screening process performed before care is rendered to evaluate the medical necessity and appropriateness of a proposed service. A behavioral health clinician or physician performs the criteria-based reviews. A prospective review helps to:
- Determine medical necessity
- Evaluate proposed treatment
- Assess level of care required
- Determine appropriate level of care prior to admission
- Identify potential for discharge planning needs and determine whether the case meets care coordination or case-management criteria
- Identify potential quality-of-care issues
Depending on first-level (i.e., prospective) review results, ValueOptions either authorizes the service or refers the service for a second-level review by a physician and/or peer reviewer. A prospective review never results in a denial of care or treatment.
Concurrent Review
A concurrent review is a process of continual reassessment of the beneficiary’s needs during treatment. The behavioral health care clinician responsible for concurrent review evaluates the beneficiary’s level-of-care needs during hospitalization. Based on medical determinations, an entire episode of medical care may be adapted to fit the beneficiary’s status and needs.
Concurrent review activities monitor appropriateness of the level of care and identify potential care coordination, discharge needs, and case management candidacy, and may include:
- A continuum of health care based on identified needs and goals
- Design and adaptation of health care initiatives for the beneficiary
- Identification of assistance needs throughout an entire episode of care
- Beneficiary and family education
Visit the “
MyHMHS for Providers” portal or fax a Higher Level of Care Treatment Report Form to 1-866-811-4422 to request a concurrent review.
Retrospective/Prepayment Review
When treatment falls within the behavioral health care ICD-9 code range of 290.0–314.9, the provider must contact ValueOptions at 1-800-700-8646 to obtain authorization. Care rendered without prior authorization will be reviewed retrospectively and may result in a penalty of up to 50 percent. The cost of this penalty will be borne by the provider, and the beneficiary will be held harmless. To initiate a retrospective review, mail a request and a copy of the medical record to:
ValueOptions
Retrospective Review
P.O. Box 551188
Jacksonville, FL 32255-1188
To initiate a retrospective review for outpatient care beyond the initial eight self-referred visits, mail a TRICARE Outpatient Retrospective Review Form to the previously listed address, or fax information to ValueOptions at 1-866-811-4422.
Non-network care rendered without authorization may be subject to prepayment review. Non-network claims submitted without prior authorization are deferred for prepayment review, which may require access to the patient’s medical record, to determine medical necessity and TRICARE coverage. Penalties may also apply.
Case Management
Certain beneficiaries require more intensive care management and coordination. These high-risk beneficiaries may be eligible for case management through ValueOptions. Case management identifies links and provides intensive coordination of behavioral health and substance use disorder services to help beneficiaries maintain clinical stability.
Case managers link beneficiaries with TRICARE resources, MTFs, and state, federal, and local community resources, and they teach beneficiaries to be proactive about accessing care. To refer a patient for a case management evaluation, call ValueOptions or submit a Case Management Referral Form. If ValueOptions accepts the case for management services, a case manager will contact the beneficiary.
Discharge Planning
Discharge planning facilitates the transition of the beneficiary to a less-restrictive level of care. Behavioral health care providers are expected to include discharge planning as a routine part of treatment. Discharge planning services are automatically considered for all TRICARE beneficiaries in facilities where ValueOptions provides utilization-management services. Discharge planning objectives include:
- Ensuring appropriate use of health care services and hospital resources
- Evaluating acuity of the cases to project resources necessary for positive discharge planning
- Identifying and using cost-effective care sites when clinically appropriate
- Ensuring appropriate admissions and avoid readmissions due to incomplete treatments
- Identifying and using all alternative sources of available funding
The provider should inform the patient about specific discharge plans and aftercare treatments, including detailed placement plans and follow-up care. After-care appointments should occur within seven days after discharge and no later than 30 days after discharge. ValueOptions must authorize all medically necessary aftercare services to ensure continuity of care. Visit the “
MyHMHS for Providers” portal or fax a Higher Level of Care Treatment Report Form to 1-866-811-4422 to submit discharge information.
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