1.0 BACKGROUND
1.1 The National Defense Authorization
Act for Fiscal Year 2015 (NDAA FY 2015), Section 703, signed into
law on December 19, 2014, removed TRICARE statutory limitations
on inpatient mental health services (30 calendar days for adults,
45 calendar days for children) and Residential Treatment Center
(RTC) care for children (150 calendar 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.
1.2 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 Necessity
Admissions occurring on or
after October 1, 1991, to all facilities (includes Diagnosis Related
Group (DRG) and non-DRG facilities).
3.2.1 Detoxification
3.2.1.1 Stays for detoxification are
covered if preauthorized as medically/psychologically necessary.
The contractor shall consider the appropriate level of care for
the patient and the intensity of services required by the patient
in determining the medical or psychological necessity of detoxification
and rehabilitation for SUD. 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.
3.2.1.2 The contractor shall, for TRICARE
Prime patients, notify the Primary Care Manager (PCM) of the admission
within four business hours of the contractor being notified.
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
Requirements
All 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.
3.3.3 The contractor
shall perform medically or psychologically necessary reviews on
a retrospective basis when the contractor is acting as a secondary
payer. 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.
3.3.4 The contractor shall obtain
any needed information and perform a retrospective review when TRICARE is
primary payer for these services and preauthorization was not obtained.
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 calendars 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 DATES
4.1 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.