Provider Handbook - Behavioral Health-Alcoholism and Other Substance Use Disorders

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Behavioral Health Services Providers Referrals & Authorizations Obtaining Referrals/Authorizations Accessing Care Programs Offered Outpatient Services Inpatient Services Residential Treatment Centers Substance Use Disorder Services Court Ordered Care Management Appeals & Reconsiderations Medical Record Documentation Billing and Claims Non-Covered Services

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Substance Use Disorder Services

Treatment for substance use disorders may include outpatient and/or inpatient services, as described below.

Inpatient Detoxification

TRICARE covers emergency and inpatient hospital services for the treatment of the acute phases of substance use withdrawal (detoxification) when the patient’s condition requires the personnel and facilities of a hospital.

The following limits apply:

Seven days per episode in a TRICARE authorized facility, if medically necessary
Services count toward 30- or 45-day inpatient behavioral health care limit
Services do not count toward 21-day rehabilitation limit

Inpatient Rehabilitation

Rehabilitation (residential or partial) is limited to 21 days per year, per benefit period.* All inpatient stays count toward the 30- or 45-day inpatient limit.

Benefits provide up to 21 days per benefit period* (combined partial and/or inpatient).
Up to seven days of detoxification are allowed per episode in addition to the 21 rehabilitative days.
Days count toward the 30- or 45-day behavioral health care inpatient limits.
Care must be provided in a TRICARE-authorized facility.
Prior authorization is always required for rehabilitation stays.
Care may occur in an inpatient or partial hospitalization setting.
A partial hospitalization rehabilitation stay counts toward the 60-day psychiatric PHP limit. (TRICARE shares the cost of this partial hospitalization rehabilitation treatment for up to 21 days at a predetermined, all-inclusive per diem rate.)

Benefits provide up to one treatment episode in a one-year period and up to three treatment episodes during the beneficiary’s lifetime.

* A benefit period starts the first day of covered treatment and ends 365 days later.

Outpatient Care

Outpatient care must be provided by an approved substance use disorder facility.

The following coverage limits apply:

Individual or group therapy: 60 visits per benefit period*
Family therapy: 15 visits per benefit period*

ValueOptions may approve additional visits, as appropriate, based on medical necessity. TRICARE does not cover non-facility-based outpatient services provided in an office-based setting for a beneficiary with a primary diagnosis of substance use disorder/dependence.

* A benefit period starts the first day of covered treatment and ends 365 days later.

Last Update: January 15, 2011