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:
5.1 Institutional
Benefits
5.1.1 Medically or psychologically necessary acute
hospital psychiatric care (see
Section 3.1);
5.1.2 Medically or psychologically necessary psychiatric
RTC care for children and adolescents, up to age 21 (see
Section 3.2);
5.1.3 Medically or psychologically necessary psychiatric
PHP care (see
Section 3.4);
5.1.4 Medically or psychologically necessary psychiatric
IOP care (see
Section 3.16).
5.2 Professional
Services
5.2.1 Individual psychotherapy, adult or child (see
Section 3.11);
5.2.5 Psychological testing and assessment (see
Section 3.10);
5.2.6 Specific mental health coverage descriptions
are outlined in eating disorder treatment (see
Section 3.15),
specific learning disorder (see
Section 3.6),
Attention Deficit Hyperactivity Disorder (ADHD) (see
Section 3.7),
and Gender Dysphoria (see
Section 1.2);
5.2.7 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 3.12).
5.2.8 Electroconvulsive treatment (Current Procedural
Terminology (CPT) procedure codes 90870 and 90871). Electroconvulsive
treatment is covered when medically or psychologically appropriate
and when rendered by qualified providers. However, the use of electric
shock as negative reinforcement (aversion therapy) is excluded.
5.2.10 Medication Assisted Treatment (MAT) (see
Section 3.18);
5.2.11 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.
5.2.12 All providers are expected to consult with,
or refer patients to, a physician for evaluation and treatment of
physical conditions that may co-exist with or contribute to a mental
disorder.
5.2.13 Transcranial
Magnetic Stimulation (TMS) (also referred to as repetitive TMA (rTMS))
for the treatment of major depressive disorder (CPT procedure codes
90867, 90868, and 90869), is proven.