TRICARE Overseas Program Provider Manual
TRICARE Overseas Program Provider Manual
TRICARE Overseas Program Provider Manual
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<strong>TRICARE</strong> overseas <strong>Program</strong><br />
<strong>Provider</strong> <strong>Manual</strong><br />
Behavioral Health Care Services: Inpatient Coverage Details<br />
Prior authorization is required for all nonemergency inpatient behavioral health care services. Psychiatric emergencies do not require<br />
prior authorization for inpatient admissions, but authorization is required for continued stay. Admissions resulting from psychiatric<br />
emergencies should be reported to the TOP contractor within 24 hours of admission or on the next business day, and must be reported<br />
within 72 hours of an admission. Authorization for continued stay is coordinated between the inpatient unit and the TOP contractor.<br />
Note: Active duty service members who receive care at military hospitals or clinics do not require prior authorization.<br />
Note: This figure is not all-inclusive and additional limitations on behavioral health care services may apply overseas.<br />
Figure 2.6<br />
SECTIoN 2<br />
<strong>TRICARE</strong> overseas <strong>Program</strong><br />
Benefits<br />
Service<br />
Acute Inpatient Psychiatric Care<br />
Description<br />
May be covered on an emergency or nonemergency basis. Prior authorization from your regional<br />
contractor is required for all nonemergency inpatient admissions. In emergency situations,<br />
authorization is required for continued stay.<br />
■ Limitations:<br />
— Patients age 19 and older: 30 days per fiscal year (FY 1 ) or in any single admission<br />
— Patients age 18 and under: 45 days per FY 1 or in any single admission<br />
— Inpatient admissions for substance use disorder detoxification and rehabilitation<br />
count toward the 30- or 45-day limit for acute inpatient psychiatric care.<br />
(Limitations may be waived if determined to be medically or psychologically necessary.)<br />
Psychiatric Partial<br />
Hospitalization <strong>Program</strong> (PHP)<br />
Psychiatric PHPs are treatment settings capable of providing interdisciplinary therapeutic services at<br />
least three hours a day, five days a week, in any combination of day, evening, night, and weekend<br />
treatment programs. The following rules apply:<br />
— Prior authorization is required. PHP admissions are not considered emergencies.<br />
— Facilities must be <strong>TRICARE</strong>-authorized.<br />
— PHPs must have participation agreements with <strong>TRICARE</strong>.<br />
■ Limitations:<br />
— PHP care is limited to 60 treatment days (whether full- or partial-day treatment) per FY 1 .<br />
These 60 days are not offset by or counted toward the 30- or 45-day limit for acute inpatient<br />
psychiatric care.<br />
(Limitations may be waived if determined to be medically or psychologically necessary.)<br />
Residential Treatment Center<br />
(RTC) Care<br />
RTC care provides extended psychiatric care for children and adolescents with psychological<br />
disorders that require continued treatment in a therapeutic environment. The following rules apply:<br />
— Facilities must be <strong>TRICARE</strong>-authorized.<br />
— Unless therapeutically contraindicated, the family and/or guardian should actively participate<br />
in the continuing care of the patient through either direct involvement at the facility or<br />
geographically distant family therapy.<br />
— Prior authorization is always required. RTC admissions are not considered emergencies.<br />
— RTC care is considered elective and will not be covered for emergencies.<br />
— Admission primarily for substance use rehabilitation is not authorized for psychiatric RTC<br />
care. In an emergency, psychiatric inpatient hospitalization must be sought first.<br />
— Care must be recommended and directed by a psychiatrist or clinical psychologist.<br />
■ Limitations:<br />
— Care is limited to 150 days per FY 1 or for a single admission. (Limitations may be waived if<br />
determined to be medically or psychologically necessary.)<br />
— RTC care is only covered for patients until reaching age 21.<br />
— RTC care does not count toward the 30- or 45-day inpatient limit.<br />
1<br />
October 1- September 30.<br />
19