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
Prospective review is conducted when a certain procedure/service requires a medical necessity review. The review is performed under the direction of a behavioral health care clinician, and its purpose includes the following:
- Determining medical necessity
- Evaluating proposed treatment
- Assessing level of care required
- Determining appropriate level of care prior to admission
- Identifying potential for discharge planning needs and determining whether the case meets care coordination or case management criteria
- Identifying potential quality-of-care issues Physicians and/or peer reviewers perform second-level reviews.
Physicians and/or peer reviewers perform second-level reviews.
Concurrent Review
Concurrent review is a process of continual reassessment of the beneficiary’s needs during treatment. Concurrent review activities monitor the patient for appropriate level of care and identify potential care coordination, discharge needs, and case management candidacy. The behavioral health care clinician responsible for concurrent review evaluates the beneficiary’s level-of-care needs during hospitalization. Based on medical determinations of levels of assistance that may be required, an entire episode of medical care may be adapted to fit the beneficiary’s status and needs.
Components 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
Retrospective/Prepayment Review
When treatment falls within the behavioral health care ICD-9 code range of 290.0–314.9, the provider/facility must contact ValueOptions at 1-800-700-8646 for a behavioral health care authorization. Care rendered without 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/facility, and the beneficiary will be held harmless. To obtain a retrospective review, mail a copy of the medical record, along with a request for retrospective review to:
ValueOptions
Retrospective Review
P.O. Box 551188
Jacksonville, FL 32255-1188
Outpatient care rendered beyond the eight unmanaged visits may be reviewed retrospectively by submitting a TRICARE Outpatient Retrospective Review Form. A copy of the denied explanation of benefits (EOB) must be attached and mailed to the address above, or faxed to ValueOptions at 1-866-811-4422.
Non-network care rendered without authorization may be subject to prepayment review. If a claim is submitted without prior authorization, it will be deferred for prepayment review for a determination of medical necessity and whether the service was a benefit. Medical records may be requested in these cases. Once the service has been reviewed, a determination is made on the claim (payment or denial).
A penalty may be applicable for care rendered without prior authorization (when authorization is required).
Case Management
Certain beneficiaries may require more intensive management and coordination of care. 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 high-risk beneficiaries to assist them in maintaining an optimal level of clinical stability.
Case managers link beneficiaries with TRICARE resources, MTFs, and state, federal, and local community resources, and they teach beneficiaries how to advocate for their own needs. You can make a referral for a case management evaluation by calling ValueOptions or completing a
Case Management Referral Form. If a beneficiary is accepted for case management services, they will be assigned a case manager who will contact the beneficiary to assist in coordination of care and accessing necessary available resources.
Discharge Planning
Discharge planning is an important function that facilitates the transition of the beneficiary into a less restrictive level of care. Behavioral health care providers are expected to make discharge planning a routine part of treatment. Discharge planning services are automatically considered for all TRICARE beneficiaries in facilities in the South Region where ValueOptions provides utilization management services. Coordination of discharge planning will occur during all initial and concurrent reviews. The objectives of discharge planning include:
- Minimize inappropriate use of hospital resources
- Evaluate acuity of the cases to project resources necessary to affect positive discharge planning
- Identify and use cost-effective care sites when clinically appropriate
- Prevent unnecessary admissions and avoid readmissions caused by incomplete course of treatment
- Locate and use all alternative sources of available funding
- Avoid either underutilization or overutilization of health care services
Discharge planning is thorough and unique to each case. The patient is to be provided with specific discharge plans and aftercare treatment, including detailed placement plans and professional follow-up. Aftercare appointments should occur within seven days after discharge and no later than 30 after discharge. ValueOptions will authorize all medically necessary aftercare services to ensure continuity of care.
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