Referral and Authorization Requirements by Category
      

ADSMs must receive behavioral health care services at an MTF when available. TRICARE Prime Remote (TPR) ADSMs can receive civilian behavioral health care with a prior authorization from their service point of contact (SPOC). All other ADSMs must have a referral from their primary care manager (PCM) and prior authorization from ValueOptions for any nonemergency behavioral health care services from a civilian network or non-network provider.

Note: Prior authorization is not required for emergency behavioral health care inpatient admissions when referred by an evaluating physician; however, the admitting facility must notify ValueOptions within 24 hours of admission.
           

Beneficiaries enrolled in TRICARE Prime (except for ADSMs) or TRICARE Prime Remote for Active Duty Family Members (TPRADFM) may receive the first eight outpatient visits per fiscal year (October 1–September 30) from a TRICARE network provider without a referral or prior authorization from ValueOptions, unless services are provided by a licensed or certified mental health counselor or pastoral counselor, in which case a physician referral and supervision are required.

After the first eight self-referred outpatient visits, prior authorization from ValueOptions is required. The initial eight self-referred outpatient visits are provided per beneficiary, per fiscal year, and not per provider.

Additionally, the following behavioral health care services require prior authorization (updated list effective April 1, 2009):

TRICARE Prime beneficiaries will pay higher out-of-pocket, point of service (POS) costs if they self-refer to a non-network provider.

To ensure coordination of care, when a TRICARE Prime beneficiary is referred for behavioral health and/or substance use care, TRICARE requires that the rendering provider submit a consult report to the PCM within 10 working days of the specialty encounter. Providers who treat TRICARE beneficiaries coming from the local MTF may receive a fax reminder to return a consult report for a recent visit or service. The office should return the consult report requested and use the designated fax reminder as the cover sheet. Use the fax number shown in the center of the reminder page. This fax number is shown only on the fax reminder sent to the providers for each beneficiary consult report request. This is to avoid having providers send documentation on all other TRICARE beneficiaries. If the beneficiary refuses to sign a medical release for the consult report, the provider is obligated to inform ValueOptions of the beneficiary’s decision within the time period previously described.
         

TRICARE and Humana Military have established the Behavioral Health Care Provider Locator and Appointment Assistance Line to help eligible ADSMs and active duty family members (ADFMs) find behavioral health care providers and schedule timely appointments for urgent and routine outpatient behavioral health care.

This service is available to all ADSMs and ADFMs enrolled in TRICARE Prime, TPR, or TPRADFM, as well as ADFMs enrolled in an overseas TRICARE Prime program option who have temporarily returned to the United States. Prior to calling the appointment assistance line, ADSMs must have a referral from their MTF PCM, SPOC, or their MTF behavioral health care clinic for civilian behavioral health care.

Note: ADSMs calling this service without an appropriate referral or authorization will only be provided with MTF points of contact.

TRICARE Prime access standards for urgent and routine medical care apply to all behavioral health care services, including appointments made through the appointment assistance line. The wait time for an initial urgent behavioral health care appointment shall generally not exceed 24 hours. The wait time for an initial routine behavioral health care appointment shall not exceed one week. Following the initial appointment, the behavioral health care provider’s medical judgment will determine the wait time for the beneficiary’s follow-up appointments.

ValueOptions manages the South Region Behavioral Health Care Provider Locator and Appointment Assistance Line. The dedicated toll-free number, 1-877-298-3514, is available from 8 a.m. to 6 p.m. in all South Region time zones, Monday through Friday, excluding federal holidays.

Note: This appointment assistance line is not a crisis intervention line. Direct all TRICARE beneficiaries seeking emergency behavioral health care assistance to call 911 or to proceed to the nearest emergency room for treatment.          
        

Beneficiaries using TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select (TRS) never need a referral, and they can receive the first eight outpatient visits without prior authorization. Services provided by a licensed or certified mental health counselor or pastoral counselor require a physician referral and supervision.

After the first eight visits, prior authorization is required. Additionally, the following services require prior authorization:

Beneficiaries using Medicare as their primary payer are not required to obtain referrals or prior authorization from ValueOptions for inpatient or outpatient behavioral health care services. These beneficiaries should follow Medicare rules for services requiring authorization. They may self-refer to any network or non-network provider who accepts Medicare. When behavioral health care benefits are exhausted under Medicare, TRICARE becomes the primary payer, and prior authorization from ValueOptions is then required.

Note: If the provider’s licensure level is recognized by Medicare, the provider must be Medicare certified. If a provider’s licensure level is not recognized by Medicare (such as a licensed or certified mental health counselor, licensed marriage and family therapist), TRICARE becomes the primary payer, prior authorization from ValueOptions is required, and TRICARE Standard cost-shares and deductibles apply, unless the beneficiary is an ADFM.