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.