Provider Handbook - Behavioral Health-Residential Treatment Centers

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Residential Treatment Centers

RTC care provides extended care for children and adolescents with psychological disorders who require continued treatment in a therapeutic environment. The provider must submit documentation with the request, and the behavioral health disorder must meet clinical review criteria before admission can be authorized.

The following rules apply:

RTC care is considered elective (nonemergency) and always requires prior authorization from ValueOptions.
Facilities must be TRICARE-authorized by the NQMC. (See the Important Provider Information section of this handbook for contact information.)
Unless therapeutically contraindicated, the family and/or guardian must actively participate in the continuing care of the patient through either direct involvement at the facility or geographically distant family therapy.
Admission primarily for substance use rehabilitation is not authorized.
For admissions to an RTC, a psychiatrist or clinical psychologist shall recommend admission and direct the treatment plan.

The following coverage limitations apply:

Care is limited to 150 days per FY or for a single admission.
RTC care is only covered for patients under age 21.

ValueOptions may approve additional days, as appropriate, based on medical necessity.

TRICARE reimburses RTC care at an all-inclusive per diem rate. The only three charges considered outside the all-inclusive RTC rate are:

Geographically distant family therapy:
The family therapist may bill and be reimbursed separately from the RTC if therapy is provided to one or both of the child’s parents residing a minimum of 250 miles from the RTC.
RTC educational services:
Educational services are covered only when local, state, or federal governments cannot provide appropriate education. TRICARE is always the last payer. For network providers, this limitation applies only if educational services are not part of the contracted per-diem rate.
Non-behavioral health care services:
These services (e.g., medical treatments for asthma or diabetes) are reimbursed separately.

Last Update: January 15, 2011