TRICARE Manuals - Display Chap 7 Sect 3.5 (Change 41, Feb 8, 2019)

Medicine

Chapter 7

Section 3.5

Substance Use Disorders (SUDs) - General

Issue Date: June 26, 1995

Authority: 32 CFR 199.4(b)(1)(iv), (e)(4), and (h)

Revision: C-25, June 15, 2018

1.0 DESCRIPTION

An SUD is a mental condition that involves a maladaptive pattern of substance use leading to clinically significant impairment or distress; impaired control over substance use; social impairment; and risky use of substance(s).

2.0 POLICY

Benefits are payable for services and supplies that are medically or psychologically necessary for the treatment of mental disorders when:

2.1 Coverage may be extended for the treatment of SUDs including management of withdrawal symptoms (detoxification), rehabilitation, and outpatient care provided by institutions or individual professional providers who meet the criteria of 32 CFR 199.6.

2.2 A mental disorder is a nervous or mental condition that involves a clinically significant behavioral or psychological syndrome or pattern that is associated with a painful symptom, such as distress, and that impairs a patient’s ability to function in one or more major life activities. A SUD is a mental condition that involves a maladaptive pattern of substance use leading to clinically significant impairment or distress; impaired control over substance use; social impairment; and risky use of a substance(s). Additionally, the mental disorder must be one of those conditions listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). “Conditions Not Attributable to a Mental Disorder,” or V codes (Z codes in the ICD-10-CM), are not considered diagnosable mental disorders. Co-occurring mental and SUDs are common and assessment should proceed as soon as it is possible to distinguish the substance related symptoms from other independent conditions.

3.0 POLICY CONSIDERATIONS

3.1 Professional And Institutional Providers Of SUD Services

3.1.1 List of authorized individual professional providers. Only the types of providers listed below are considered qualified providers of SUD services. The person providing the care must meet the criteria of 32 CFR 199.6, whether that person is an individual professional provider or is employed by another authorized provider.

• Psychiatrists and other physicians (see Section 3.18 for Medication Assisted Treatment (MAT) requirements);

• Nurse Practitioners (NPs) and Physician’s Assistants (PAs) (see Section 3.18 for MAT requirements);

• Clinical psychologists;

• Certified Psychiatric Nurse Specialists (CPNSs);

• Certified Clinical Social Workers (CCSWs);

• TRICARE Certified Mental Health Counselors (TCMHCs);

• Certified marriage and family therapists;

• Pastoral counselors; and

• Supervised Mental Health Counselors (SMHCs).

3.1.2 List of institutional providers. Only the type of institutional providers listed below are considered qualified institutional providers of SUD services. The care must meet the criteria of 32 CFR 199.6.

• Acute Hospital Psychiatric Care;

• Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRFs);

• SUD Partial Hospitalization Programs (PHPs);

• Intensive Outpatient Programs (IOPs); and

• Opioid Treatment Programs (OTPs).

Note: Professional staff of institutions providing mental health services. For professional services billed by institutional providers that are authorized by the Defense Health Agency (DHA), reviewers may assume that all professional staff meet regulatory criteria. Any evidence to the contrary is to be brought to the attention of the TRICARE Regional Office (TRO), immediately. Contractors shall notify institutional providers within their jurisdictions that payment is authorized only for professional services provided by employees meeting the program requirements. In any situation where the contractor obtains evidence that an institutions billing for professional services of unqualified staff, the case is to be submitted to the DHA Office of Program Integrity (PI).

3.2 Covered Services And Treatments

All claims for treatment of mental disorders are subject to review in accordance with claims processing procedures contained in the TRICARE Operations Manual (TOM). The following services and supplies are covered:

3.2.1 Institutional Benefits

3.2.1.1 Emergency and inpatient hospital services are covered when medically or psychologically necessary for the active medial treatment of the acute phases of substance use, management of withdrawal symptoms (detoxification), for stabilization, and for treatment of medical complications of SUDs (see Section 3.1);

3.2.1.2 Medically or psychologically necessary SUDRF care (see Section 3.3);

3.2.1.3 Medically or psychologically necessary SUD PHP care (see Section 3.4);

3.2.1.4 Medically or psychologically necessary SUD IOP care (see Section 3.16);

3.2.1.5 Medically or psychologically necessary SUD OTP care (see Section 3.17);

Note: Institutional benefits for mental health disorders are covered in Section 3.8.

3.2.2 Professional Services

3.2.2.1 Individual psychotherapy, adult or child (see Section 3.11);

3.2.2.2 Group psychotherapy (see Section 3.11);

3.2.2.3 Family or conjoint psychotherapy (see Section 3.12);

3.2.2.4 Psychoanalysis (see Section 3.11, paragraph 4.3.3);

3.2.2.5 Psychological testing and assessment (see Section 3.10);

3.2.2.6 Administration of psychotropic drugs. All patients receiving psychotropic drugs must be under the care of a qualified mental health provider authorized by state licensure to prescribe drugs (see Section 3.13);

3.2.2.7 Collateral visits (see Section 3.14, paragraph 4.3.4);

3.2.2.8 MAT (see Section 3.18);

3.2.2.9 Ancillary therapies (no code, as separate reimbursement is not permitted). Includes art, music, dance, occupational, and other ancillary therapies, when included by the attending provider in an approved inpatient treatment plan and under the clinical supervision of a licensed doctoral level mental health professional. These ancillary therapies are not separately reimbursed professional services but are included within the institutional reimbursement.

Note: Professional services for mental health disorders are covered in Section 3.8.

3.3 Confidentiality

Release of any patient identifying information, including that required to adjudicate a claim, must comply with the provisions of 42 United States Code (USC) 290dd-3, which governs the release of medical and other information from the records of patients undergoing treatment of SUD. If the patient refuses to authorize the release of medical records which are, in the opinion of the contractor necessary to determine benefits on a claim for treatment of SUD the claim will be denied.

4.0 REFERRAL AND PREAUTHORIZATION REQUIREMENTS

4.1 Referral

Normal TRICARE Prime referral requirements shall apply under the following conditions:

4.1.1 A Primary Care Manager (PCM) referral is required for inpatient (non-emergency psychiatric hospitalization, inpatient/residential) SUD services.

4.1.2 A PCM referral is required for non-office based, outpatient (e.g., PHP, IOP, and OTP) SUD services. However, if the non-office based, outpatient SUD provider is a network provider, a request for preauthorization from the network provider to the contractor may be accepted in lieu of a PCM referral.

4.1.3 Office-based, outpatient SUD services by an authorized TRICARE network provider do not require a referral.

4.1.4 Point Of Service (POS) charges shall apply when services are rendered by a non-network office-based, outpatient SUD individual provider without a PCM referral when network providers are available in the TRICARE Prime Service Area (PSA).

4.2 Preauthorization

4.2.1 Medically or psychologically necessary outpatient SUD (PHP, IOP, OTP, or office-based) visits do not require preauthorization. However, the contractor may utilize preauthorization as a means of ensuring medical or psychological necessity absent a PCM referral (see paragraph 4.1.2).

4.2.2 Preauthorization is required for all non-emergency acute care hospitalization and inpatient/residential SUDRF levels of care. Contractors may establish additional preauthorization requirements in accordance with the TOM, Chapter 8, Section 5, paragraph 4.0.

4.2.3 Inpatient hospital services are considered medically necessary only when the patient’s condition is such that the personnel and facilities of a hospital are required. Preauthorization is not required for emergency admissions, but authorization for a continuation of services must be obtained promptly (see Section 3.1, paragraph 3.4.2).

5.0 Exclusions

5.1 Aversion therapy: The programmed use of physical measures, such as electric shock, alcohol or other drugs (except Antabuse®) as negative reinforcement is not covered, even if recommended by a physician. All professional and institutional charges associated with a rehabilitation treatment program that uses aversion therapy must also be denied.

5.2 Domiciliary settings: Domiciliary facilities, generally referred to as halfway or quarterway houses, are not authorized providers. Charges for services provided by these facilities are not covered.

5.3 SUD treatments that are considered unproven and do not meet TRICARE’s reliable evidence standards as proven medical care under 32 CFR 199.4(g)(15).

6.0 EFFECTIVE DATES

6.1 MAT provided in a SUDRF only, November 21, 2013.

6.2 Removal of day limits in any fiscal year for TRICARE beneficiaries of all ages for the provision of inpatient hospitalization and inpatient/residential SUDRF services on or after December 19, 2014.

6.3 Removal of remaining quantitative limitations on mental health and SUD care, and inclusion of IOP, OTP, Office-Based Opioid Treatment (OBOT), and MAT outside of an SUDRF, October 3, 2016.

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