1.0 BACKGROUND
1.1 In the National Defense Authorization Act for
Fiscal Year 1991 (NDAA FY 1991), Public Law 101-510 and the Defense
Appropriations Act for 1991, Public Law 101-511, Congress firmly
addressed the problem of spiraling costs for mental health services.
Motivated by the desire to bring mental health care costs under
control, Congress in both the Authorization and Appropriations Acts
established certain benefit changes and management procedures. These
statutes made two principal changes. First, they established new
day limits for inpatient mental health services and secondly, they
mandated prior authorization for all nonemergency inpatient mental
health admissions, with required certification of emergency admissions
within 72 hours.
1.2 The NDAA FY 2015, Section
703, signed into law on December 19, 2014, removed TRICARE statutory
limitations on inpatient mental health services (30 days for adults,
45 days for children) and Residential Treatment Center (RTC) care
for children (150 days), including the corresponding waiver provisions.
The removal of inpatient days for mental health services, which
placed quantitative limitations on mental health treatment that
do not exist for medical or surgical care, is consistent with principles
of mental health parity. Further, the Department believes these
changes will reduce stigma and enhance access to care, which continue
to be high priorities within the Department of Defense (DoD). As
a result, inpatient mental health services, regardless of length/quantity,
may be covered as long as the care is considered medically or psychologically
necessary and appropriate.
1.3 With the implementation
of the Final Rule, Federal Register, Volume 81, No. 171, September
2, 2016, TRICARE Mental Health and SUD Treatment, TRICARE eliminated
all remaining regulatory quantitative limits on mental health care,
consistent with mental health parity, to include the 21-day limit
for SUD rehabilitation.
2.0 POLICY
Preadmission and continued stay authorization
is required before nonemergency
inpatient and residential services for SUDs may be
cost-shared. Preadmission and continued stay authorization is required
for both detoxification and rehabilitation services. To comply with
the statutory requirements and to avoid denial, requests for preadmission
authorization on weekends and holidays are discouraged. All admissions
for rehabilitation are elective and must be authorized as
medically/psychologically necessary prior to admission. The admission
criteria shall not be considered satisfied unless the patient has
been personally evaluated by a physician or other authorized health
care professional with admitting privileges to the facility to which
the patient is being admitted prior to the admission.
3.0 POLICY
CONSIDERATIONS
3.1 Treatment
of Mental Disorders
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 of Mental Disorders (DSM) or a mental
health diagnosis in 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. Benefits are limited for certain mental
disorders, such as specific developmental disorders. 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
Criteria
for Determining Medical or Psychological NecessityAdmissions occurring on or after October 1,
1991, to all facilities (includes Diagnosis Related Group (DRG)
and non-DRG facilities).
3.2.1 Detoxification: Stays for
detoxification are covered if preauthorized as medically/psychologically
necessary. In determining the medical or psychological necessity
of detoxification and rehabilitation for SUD, the evaluation conducted
by the Director, Defense Health Agency (DHA), or designee, shall
consider the appropriate level of care for the patient and the intensity
of services required by the patient. Emergency and inpatient hospital
services are covered when medically necessary for the active medical
stabilization, and for treatment of medical complications of SUD as evaluated
by a physician or other authorized health care professional.
Authorization prior to admission is not required in the case of
an emergency requiring an inpatient acute level of care, but authorization for
a continuation of services must be obtained promptly. Admissions
resulting from a bona fide emergency shall be reported within 24
hours of the admission or the next business day after the admission
to the contractor. Emergency and 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. All
inpatient/residential Substance Use Disorder Rehabilitation Facility
(SUDRF) care, including non-emergent detoxification services provided
in a SUDRF as a part of the Episode Of Care (EOC), must be preauthorized.
3.2.2 Rehabilitative
care: The patient’s condition must be such that rehabilitation for
SUD must be provided in a hospital or a freestanding inpatient
SUD treatment program. Rehabilitation stays are covered if preauthorized
as medically/psychologically necessary. The
concept of an emergency admission does not apply to rehabilitative
care.
3.3 Preauthorization
RequirementsAll
non-emergency admissions to an inpatient/residential SUD detoxification
and rehabilitation program must be authorized prior to the admission.
The criteria for preauthorization shall be those set forth in paragraph 3.2.
In applying those criteria in the context of preauthorization review,
special emphasis is placed on the development of a specific individualized
treatment plan, consistent with those criteria and reasonably expected
to be effective, for that individual patient.
3.3.1 The request for preauthorization must be received
by the reviewer designated by the Director, DHA, or
designee, prior to the planned admission. In general,
the decision regarding preauthorization shall be made within one
business day of receipt of a request for preauthorization, and shall
be followed with written confirmation. In the case of an authorization
issued after an admission resulting from approval of a request made
prior to the admission, the effective date of the authorization shall
be the date of the receipt of the request. If the request on which
the approved authorization is based was made after the admission
(and the case was not an emergency admission), the effective date
of the authorization shall still be the date of receipt of the request. If
the care is found not medically or psychologically necessary, and
is not approved, the provider is liable for the services, but has
the right to appeal the “not medically or psychologically necessary”
determination. Only non-network participating providers may appeal
as network providers are never appropriate appealing parties.
3.3.2 When the beneficiary has Other Health Insurance
(OHI) that provides coverage, exception to the preauthorization
requirements will apply as provided in
Chapter 1, Section 6.1, paragraph 1.12. When
the contractor is acting as a secondary payer, any medically
or
psychologically necessary reviews shall be performed
on a retrospective basis.
For beneficiaries with Medicare,
preauthorization requirements apply when TRICARE is the primary
payer. As a secondary payer, TRICARE will rely on, and not replicate,
Medicare’s determination of medical or psychological necessity and
appropriateness in all circumstances where Medicare is the primary
payer. When the beneficiary has OHI that is primary to TRICARE,
all double coverage provisions in the TRICARE Reimbursement Manual
(TRM), Chapter 4, shall apply. In the event that
TRICARE is primary payer for these services and preauthorization
was not obtained, the contractor shall obtain the necessary information
and perform a retrospective review.
3.4 Payment Responsibility
Any
inpatient mental health care obtained for inpatient/rehabilitation SUD
detoxification and rehabilitation without requesting preadmission
authorization, without following concurrent review requirements,
in which the services are determined excluded by reason of being
not medically or psychologically necessary,
is not the responsibility of the patient or the patient’s family
until:
3.4.1 Receipt
of written notification by TRICARE or a TRICARE contractor
that the services are not authorized; or
3.4.2 Signing of a written statement from the provider
which specifically identifies the services which will not be reimbursed.
The beneficiary must agree, in writing, to personally pay for the
non-reimbursable services. General statements, such as those signed
at admission, do not qualify.
3.5 Concurrent Review
Concurrent
review of the necessity for continued stay will be conducted
no
less frequently than every 30 days. The criteria
for concurrent review shall be those set forth in
paragraph 3.2. In applying those
criteria in the context of concurrent review, special emphasis is
placed on evaluating the progress being made in the active clinical
treatment being provided and on developing/refining appropriate discharge
plans. In general, the decision regarding concurrent review shall
be made within one business day of the review, and shall be followed
with written confirmation.
4.0 EFFECTIVE DATES4.1 Removal of day limits in any
fiscal year for TRICARE beneficiaries of all ages for the provision
of inpatient/residential SUD services on or after December 19, 2014.
4.2 Removal of quantitative limits
on mental health and SUD care, October 3, 2016.