Provider Handbook - Behavioral Health-Provider Responsibilities

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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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Provider Responsibilities

Office and Appointment Access Standards

By signing a TRICARE contract, network providers are obligated to adhere to all contract requirements. One of the requirements is to meet all office and appointment access standards as follows:

Wait time for specialty care appointments will be based on the nature of the care required, but will not exceed four weeks. Behavioral health care is considered a specialty. The PCM determines the level of urgency.
Office waiting times for nonemergency situations will not exceed 30 minutes. Providers who are not able to adhere to these standards should notify the patient and offer to reschedule.

Balance Billing

Network providers may only bill TRICARE beneficiaries for applicable deductible, copayment, or cost-share amounts, but may not bill for charges that exceed contractually allowed payment rates. Because network providers have contractually agreed to adhere to these provisions, TRICARE beneficiaries will be referred first to a network provider.

Non-network providers who do accept assignment (participating providers) are limited to collecting the TRICARE-allowable charge. If the billed charge is less than the allowable charge, the billed charge becomes the allowable charge. This only applies to services covered by TRICARE.

When a non-network provider does not accept assignment on a claim (nonparticipating provider), the provider may collect applicable deductibles and/or cost-shares and any outstanding amounts up to 15 percent above the TRICARE-allowable charge (shown on the remittance advice) from a TRICARE beneficiary. If the billed charge is less than the TRICARE-allowable charge, the billed charge becomes the billable amount to the beneficiary. TRICARE discourages military families from using non-network nonparticipating providers.

This applies only to services covered by TRICARE. TRICARE’s balance-billing limit also applies when other health insurance (OHI) is involved. Providers are limited to collecting the amount described previously. Generally, the OHI payment, when combined with TRICARE’s payment, represents the total amount a provider can bill.

Non-compliance with these balance-billing requirements by any TRICARE provider may affect that provider’s TRICARE and/or Medicare status.

Release of Medical Records

The provider should request each beneficiary sign a release of information, to include all ancillary services, in order to release medical information. Beneficiary records should be maintained in accordance with all state and federal regulations. Providers are allowed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to release information regarding treatment, payment, and operations to ValueOptions without the beneficiary’s authorization. This includes record requests for validation audits conducted by the National Quality Monitoring Contractor (NQMC), Maximus, Inc. (Maximus), as well as ValueOptions’ Quality and Utilization Management activities.

Waiver of Non-Covered Services

TRICARE beneficiaries must be properly informed, in advance, of specific services and procedures that are not covered under the TRICARE benefit. A network provider may utilize the “waiver of non-covered services” by informing the beneficiary, in advance, that TRICARE does not cover a particular service or procedure. The beneficiary must agree, in advance and in writing, to accept financial responsibility for the services to be rendered. However, if the provider does not obtain a proper legal, signed waiver and the service or procedure is not authorized, the provider is expected to accept full financial liability for the cost of the service or procedure rendered.

For the beneficiary to be considered fully informed, TRICARE regulations require that:

The agreement is documented prior to the specific non-covered services being rendered.
The agreement is in writing with appropriate signature obtained.
The specific treatment, rendering provider, cost of services, and date(s) of service are documented.
General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or not allowable.
Providers should maintain copies of the waiver in their office and fully inform beneficiaries in advance when specific services or procedures are not covered.

Nonavailability Statements

A nonavailability statement (NAS) is required for all nonemergency behavioral health care admissions. An NAS is a certification from an MTF stating that it cannot provide a specific required service at a particular time to a nonenrolled (i.e., non-TRICARE Prime) beneficiary residing within the MTF catchment area.

Providers should advise TRICARE beneficiaries to check with the beneficiary counseling and assistance coordinator at the local MTF to find out if an NAS is required before obtaining nonemergency inpatient behavioral health care services. An NAS does not take the place of an authorization for those services requiring prior authorization.

Last Reviewed: August 9, 2010