1.0 BACKGROUND
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.
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. 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
The contractor shall use established
criteria for preadmission, concurrent review, and continued stay
decisions. Medical and psychological necessity will determine the
Length-of-Stay (LOS) for treatment in an acute inpatient mental
health care facility.
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 Diagnostic and Statistical
Manual of Mental Disorders (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
The contractor shall consider
the appropriate level of care for the patient, the intensity of
services required by the patient, and the availability of that care
in determining the medical or psychological necessity of acute inpatient mental
health services. 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 imminent
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 imminent 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 contractor 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 contractor 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 The contractor
shall obtain any needed information and perform a retrospective
review if TRICARE is the primary payer for these services, and preauthorization
was not obtained. 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. 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.
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 at
least weekly. Concurrent review will apply to all TRICARE patients,
including Active Duty Service Members (ADSMs). 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.