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.