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.