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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 7
Section 3.17
Opioid Treatment Program (OTP)
Issue Date:  June 13, 2017
Authority:  32 CFR 199.4(b)(11)
Revision:  C-25, June 15, 2018
With the implementation of the Final Rule, Federal Register, Volume 81, No 171, September 2, 2016, TRICARE mental health and Substance Use Disorder (SUD) treatment, the Defense Health Agency (DHA) added OTPs as a covered benefit to the TRICARE Basic program. This added level of care improves the availability of SUD services. The intent is to provide a needed service and to allow more efficient use of resources for needed SUD care.
OTPs are service settings for opioid treatment, either freestanding or hospital based, that adhere to the Department of Health and Human Services’ (DHHS’) regulations at 42 CFR Part 8 and use medications indicated and approved by the Food and Drug Administration (FDA). Treatment in OTPs provides a comprehensive, individually tailored program of medication therapy integrated with psychosocial and medical treatment and support services that address factors affecting each patient, as certified by the Center for Substance Abuse Treatment (CSAT) of the DHHS’ Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment in OTPs can include management of withdrawal symptoms (detoxification) from opioids and medically supervised withdrawal from maintenance medications. Patients receiving care for substance use and co-occurring disorder care can be referred to, or otherwise concurrently enrolled in, OTPs. Medication Assisted Treatment (MAT) is a TRICARE covered benefit (see Section 3.18) provided in OTPs by TRICARE authorized providers when medically and psychologically necessary. MAT is a combination of pharmacotherapy, medical treatment, and individually tailored psychosocial and support services.
3.1  In order to qualify for mental health benefits, the patient must be diagnosed by a licensed, qualified mental health professional to be suffering from a mental disorder, according to the criteria listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) or a mental health diagnosis in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) for diagnoses made before the mandated date, as directed by Health and Human Services (HHS), for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) implementation, after which the ICD-10-CM diagnoses must be used. No benefits are payable for “Conditions Not Attributable to a Mental Disorder,” or ICD-9-CM V codes, or ICD-10-CM Z codes. 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. In order for treatment of a mental disorder to be medically or psychologically necessary, the patient must, as a result of a diagnosed mental disorder, be experiencing both physical or psychological distress and an impairment in his or her ability to function in appropriate occupational, educational or social roles. It is generally the degree to which the patient’s ability to function is impaired that determines the level of care (if any) required to treat the patient’s condition.
3.2  A Primary Care Manager (PCM) referral is required for OTP services. Preauthorization is not required for OTP services. However, if the OTP provider is a network provider, a request for preauthorization from the network provider to the contractor may be accepted in lieu of PCM referral. Contractors remain responsible for ensuring covered care is medically and psychologically necessary and appropriate. See Sections 3.5 and 3.8 regarding referral and preauthorization requirements.
3.3  TRICARE adopts the treatment standards, including criteria for determining medical or psychological necessity, for OTP services, that are set forth in 42 CFR Part 8.
3.4  All services, supplies, equipment, and space necessary to fulfill the requirements of each patient’s individualized diagnosis and treatment plan are included in the reimbursement approved for an authorized OTP.
3.5  Authorized OTPs must enter into participation agreements for services and supplies that are included in the reimbursement approved for an authorized OTP.
3.6  OTPs will be reimbursed in accordance with the TRICARE Reimbursement Manual (TRM), Chapter 7, Section 5.
The programmed use of physical measures, such as electric shock, alcohol, or other drugs as negative reinforcement (aversion therapy) is not covered, even if recommended by a physician.
October 3, 2016.
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