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.
2.0 POLICY
2.1 Effective
December 19, 2014, day limits in any fiscal year are removed for
TRICARE beneficiaries of all ages for the provision of acute inpatient
mental health services. Criteria for medical and psychological necessity
continue to apply for inpatient mental health services and take
into account the level, intensity, and availability of the care
needs of the patient.
2.2 Preadmission and continued stay
authorization is required before nonemergency inpatient mental health
services may be provided and cost-shared. Prompt continued stay
authorization is required after emergency admissions. To avoid denial,
requests for preadmission authorization on weekends and holidays
are discouraged. 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
Medical and psychological necessity
will determine the Length-of-Stay (LOS) for treatment in an acute
inpatient mental health care facility. The contractor shall use
established criteria for preadmission, concurrent review, and continued
stay decisions. If a case involves both Substance Use Disorder (SUD)
and other Diagnostic and Statistical Manual of Mental Disorders (DSM)
diagnoses, the 21-day limit would apply if the patient was admitted
to a Diagnosis-Related Group (DRG) exempt SUD rehabilitation unit.
3.1 Treatment
of Mental Disorders
In order to qualify for mental health benefits,
the patient must be diagnosed by an authorized licensed, qualified
mental health professional to be suffering from a mental disorder,
according to the criteria listed in the current edition of the DSM.
Benefits are limited for certain mental disorders, such as specific
learning disorders. No benefits are payable for “Conditions Not
Attributable to a Mental Disorder”, or International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) V codes,
or International Classification of Diseases, 10th Revision, Clinical
Modification (ICD-10-CM) Z codes. Co-occurring
mental and Substance Use Disorders (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 Necessity
In determining the medical or psychological
necessity of acute inpatient mental health services, the evaluation
conducted by the Director, Defense
Health Agency (DHA) (or designee) shall consider the appropriate
level of care for the patient, the intensity of services required
by the patient, and the availability of that care. The purpose of
such acute inpatient care is to stabilize a life-threatening or
severely disabling condition within the context of a brief, intensive
model of inpatient care in order to permit management of the patient’s
condition at a less intensive level of care. Such care is appropriate
only if the patient requires services of an intensity and nature
that are generally recognized as being effectively and safely provided
only in an acute inpatient hospital setting. Acute inpatient care
shall not be considered necessary unless the patient:
3.2.1 Needs to be
observed and assessed on a 24-hour basis by skilled nursing staff,
and/or
3.2.2 Requires
continued intervention by a multidisciplinary treatment team; and
in addition, at least
one of the following
criteria is determined to be met:
3.2.2.1 Patient poses
a serious risk of harm to self and/or others.
3.2.2.2 Patient is in
need of high dosage, intensive medication or somatic and/or psychological treatment,
with potentially serious side effects.
3.2.2.3 Patient has
acute disturbances of mood, behavior, or thinking.
3.3 Emergency
Admissions
Admission to an acute inpatient hospital
setting may be on an emergency or on a non-emergency basis. In order
for an admission to qualify as an emergency, the following criteria,
in addition to those in
paragraph 3.2 must be met:
3.3.1 The patient
must be at immediate risk of serious harm to self and or others
based on a psychiatric evaluation performed by a physician (or other
qualified mental health professional with hospital admission authority);
and
3.3.2 The
patient requires immediate continuous skilled observation and treatment
at the acute psychiatric level of care.
3.4 Preauthorization
Requirements
All non-emergency admissions to
an acute inpatient hospital level of care 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.
3.4.1 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 necessary, however, and is not
approved, the provider is liable for the services but has the right
to appeal the “not medically necessary” determination. Only non-network
providers may appeal as network providers are never appropriate
appealing parties.
3.4.2 Authorization
prior to admission is not required in the case of a psychiatric
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 psychiatric emergency should be reported within
24 hours of the admission or the next business day after the admission,
but must be reported to the Director,
DHA or a designee, within 72 hours of the admission. In the case
of an emergency admission authorization resulting from approval
of a request made within 72 hours of the admission, the effective
date of the authorization shall be the date of the admission. However,
if it is determined that the case was not a bona fide psychiatric
emergency admission (but the admission can be authorized as medically
or psychologically necessary), the effective date of the authorization
shall be the date of the receipt of the request.
3.4.3 Preadmission authorization is required
even when the beneficiary has Other Health Insurance (OHI) because
the statutory requirement is applicable to every case in which payment
is sought, regardless of whether it is first payer or second payer
basis.
When a beneficiary has OHI that provides coverage,
an exception to prior authorization requirements will apply as provided
in Chapter 1, Section 6.1, paragraph 1.11. For
beneficiaries with Medicare, preauthorization requirements apply when
TRICARE is 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 the primary payer for
these services, and preauthorization was not obtained, the contractor
shall obtain the necessary information and perform a retrospective
review.
3.5 Payment Responsibility
Any
inpatient mental health care obtained without requesting preadmission
authorization or rendered without following concurrent review requirements,
in which the services are determined excluded by reason of being
not medically necessary, is not the responsibility of the patient
or the patient’s family until:
3.5.1 Receipt
of written notification by TRICARE or a TRICARE contractor that
the services are not authorized; or
3.5.2 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.
3.6 Concurrent
Review
Concurrent review of the necessity
for continued stay will be conducted. 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
DATES
4.1 Inpatient
services provided on or after October 1, 1991.
4.2 Removal
of day limits in any fiscal year for TRICARE beneficiaries of all
ages for the provision of acute inpatient mental health services
on or after December 19, 2014.