• Emergency behavioral health care: Emergency care does not require prior authorization. However, if a patient is admitted, the facility must report the admission to ValueOptions within 24 hours of the admission or the next business day (but within 72 hours) to obtain authorization for continued stay.
• Outpatient behavioral health care: Except for active duty service members (ADSMs), TRICARE beneficiaries (including TRICARE Prime beneficiaries) do not need referrals or prior authorizations for the first eight outpatient behavioral health care visits per fiscal year (FY) (October 1–September 30) for medically necessary treatment for covered conditions by network providers who are authorized under TRICARE regulations to see patients independently. After the initial eight visits, prior authorization is required. Note: TRICARE only covers one initial evaluation—either a psychiatric diagnostic exam (Current Procedural Terminology [CPT®] code 90801) or an interactive diagnostic exam (CPT code 90802)—per FY. This initial evaluation counts toward the first eight self-referred outpatient visits. Additional evaluations in the same FY require prior-authorization from Humana Military, regardless of whether the first eight visits without a referral have been met. Requests for prior authorizations for additional evaluations may be made through the secure “MyHMHS for Providers” portal, or by faxing  a TRICARE Outpatient Treatment Report form to ValueOptions at 1-866-811-4422.
• Visits to licensed or certified mental health and pastoral counselors: Physician referrals (i.e., seeing the patient, performing an evaluation, and making an initial diagnosis before referring the patient) and supervision (i.e., regularly communicating with the counselor about the treatment plan) are required for all visits (including the first eight) to licensed or certified mental health and pastoral counselors, and similar non-independent providers whose services require referral from a TRICARE-authorized physician.  The counselor must keep a copy of the referral in the patient’s chart. When filing a claim, the counselor must indicate the referring physician’s name in Box 17/17a/17b of the claim form to certify that he or she reported (or will report), in writing, treatment results to the referring physician, as requested. Due to the similarity of the requirements for licensure, certification, experience, and education, pastoral counselors may elect to be authorized as either pastoral counselors or certified marriage and family therapists. Pastoral counselors who elect to be authorized as certified marriage and family therapists do not require physician referrals and supervision.
• Nonemergency inpatient behavioral health care: All nonemergency inpatient care requires prior authorization from ValueOptions. A non-enrolled (i.e., non-TRICARE Prime) beneficiary must also obtain a nonavailability statement (NAS) for a nonemergency inpatient admission. See “Nonavailability Statements” later in this section.

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 primary care manager (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 to avoid having providers send documentation on all other TRICARE beneficiaries.

Note: If the beneficiary refuses to sign a medical release for the consult report, the provider is obligated to inform TRICARE South of the beneficiary’s decision within the time period previously described.

Note for ADSMs:  ADSMs are required to receive behavioral health care at MTFs except in emergencies or in accordance with TRICARE Prime Remote regulations. ADSMs must have referrals and prior authorizations from their PCMs and ValueOptions before seeking nonemergency behavioral health care. TRICARE Prime Remote (TPR) ADSMs must obtain prior authorizations from ValueOptions and their service points of contact (SPOCs) for all behavioral health care services. ADSMs do not need referrals or prior authorizations to use the TRICARE Assistance Program (TRIAP), which provides non-medical counseling services.

Note for TRICARE For Life (TFL) beneficiaries: TFL beneficiaries must follow Medicare rules, as Medicare is their primary coverage. For any services not covered by Medicare but covered by TRICARE (e.g., services Medicare does not cover or if Medicare benefits are exhausted) TRICARE is the primary payer and beneficiaries must follow TRICARE rules. For details contact the Medicare Plan Administrator at 1-800-633-4227.

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