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.