TRICARE Overseas Program Provider Manual

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TRICARE overseas Program Provider Manual Behavioral Health Care Services: outpatient Coverage Details Figure 2.5 Service outpatient Psychotherapy* (physician referral and supervision required when seeing licensed or certified mental health counselors and pastoral counselors) Description The following outpatient psychotherapy limits apply: ■ Psychotherapy: Two sessions per week, in any combination of the following types: — Individual (adult or child): 60 minutes per session; may extend to 120 minutes for crisis intervention — Family or conjoint: 90 minutes per session; may extend to 180 minutes for crisis intervention — Group: 90 minutes per session ■ Collateral visits Up to 60 minutes per visit (Collateral visits are counted as individual psychotherapy sessions. Beneficiaries have the option of combining collateral visits with other individual or group psychotherapy visits.) Psychoanalysis Psychological Testing and Assessment Psychoanalysis differs from psychotherapy and requires prior authorization. After prior authorization is obtained, treatment must be given by approved providers who are specifically trained in psychoanalysis. Testing and assessment is generally covered when medically or psychologically necessary and provided in conjunction with otherwise-covered psychotherapy. Psychological tests are considered to be diagnostic services and are not counted toward the limit of two psychotherapy visits per week. ■ Limitations: — Testing and assessment is generally limited to six hours per fiscal year (FY 1 ). Any testing beyond six hours requires a review for medical necessity. Psychological testing must be medically necessary and not for educational purposes. ■ Exclusions: Psychological testing is not covered for the following circumstances: • Academic placement • Job placement • Child-custody disputes • General screening in the absence of specific symptoms • Teacher or parental referrals • Testing to determine whether a beneficiary has a learning disability • Diagnosed, specific learning disorders or learning disabilities Medication Management If you are taking prescription medications for a behavioral health condition, you must be under the care of a provider who is authorized to prescribe those medications. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible. Medication-management appointments are medical appointments and do not count against the first eight outpatient behavioral health care visits per FY. 1 1 For ADFM, the first 8 outpatient visits per FY 1 do not require authorization. For ADSM, authorization is required for all behavioral health care. Also, certain clinical preventive services do not require authorization when received from a Network Provider. If you are unsure about covered services, please contact International SOS and press option #5 to speak with a member of the TOP Provider Support Services staff. 2 October 1- September 30. 18
TRICARE overseas Program Provider Manual Behavioral Health Care Services: Inpatient Coverage Details Prior authorization is required for all nonemergency inpatient behavioral health care services. Psychiatric emergencies do not require prior authorization for inpatient admissions, but authorization is required for continued stay. Admissions resulting from psychiatric emergencies should be reported to the TOP contractor within 24 hours of admission or on the next business day, and must be reported within 72 hours of an admission. Authorization for continued stay is coordinated between the inpatient unit and the TOP contractor. Note: Active duty service members who receive care at military hospitals or clinics do not require prior authorization. Note: This figure is not all-inclusive and additional limitations on behavioral health care services may apply overseas. Figure 2.6 SECTIoN 2 TRICARE overseas Program Benefits Service Acute Inpatient Psychiatric Care Description May be covered on an emergency or nonemergency basis. Prior authorization from your regional contractor is required for all nonemergency inpatient admissions. In emergency situations, authorization is required for continued stay. ■ Limitations: — Patients age 19 and older: 30 days per fiscal year (FY 1 ) or in any single admission — Patients age 18 and under: 45 days per FY 1 or in any single admission — Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30- or 45-day limit for acute inpatient psychiatric care. (Limitations may be waived if determined to be medically or psychologically necessary.) Psychiatric Partial Hospitalization Program (PHP) Psychiatric PHPs are treatment settings capable of providing interdisciplinary therapeutic services at least three hours a day, five days a week, in any combination of day, evening, night, and weekend treatment programs. The following rules apply: — Prior authorization is required. PHP admissions are not considered emergencies. — Facilities must be TRICARE-authorized. — PHPs must have participation agreements with TRICARE. ■ Limitations: — PHP care is limited to 60 treatment days (whether full- or partial-day treatment) per FY 1 . These 60 days are not offset by or counted toward the 30- or 45-day limit for acute inpatient psychiatric care. (Limitations may be waived if determined to be medically or psychologically necessary.) Residential Treatment Center (RTC) Care RTC care provides extended psychiatric care for children and adolescents with psychological disorders that require continued treatment in a therapeutic environment. The following rules apply: — Facilities must be TRICARE-authorized. — Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient through either direct involvement at the facility or geographically distant family therapy. — Prior authorization is always required. RTC admissions are not considered emergencies. — RTC care is considered elective and will not be covered for emergencies. — Admission primarily for substance use rehabilitation is not authorized for psychiatric RTC care. In an emergency, psychiatric inpatient hospitalization must be sought first. — Care must be recommended and directed by a psychiatrist or clinical psychologist. ■ Limitations: — Care is limited to 150 days per FY 1 or for a single admission. (Limitations may be waived if determined to be medically or psychologically necessary.) — RTC care is only covered for patients until reaching age 21. — RTC care does not count toward the 30- or 45-day inpatient limit. 1 October 1- September 30. 19
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TRICARE Overseas Program Provider Manual

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