Behavioral Health Prior Authorization Requirements

On November 1, 2006, TriWest replaced the "Medical Necessity Review List" with the Prior Authorization List (PAL). The PAL has again been updated effective March 15; however, we encourage you to begin using it immediately. 

Behavioral Health providers need to fully complete the appropriate behavioral health forms to expedite the prior authorization process. Forms can be found on www.triwest.com where you click the "Find a Form" tab located at the top of the homepage, select "provider forms" and scroll down to "behavioral health" to find the specific forms for specific levels of care requests.  The forms have recently been updated to include the National Provider Identifier (NPI).

TRICARE Prime and Standard beneficiaries are eligible for eight self-referred routine outpatient behavioral health visits per fiscal year. "Self referred" means it is not necessary to have a referral from their primary care manager (PCM) to see a Behavioral Health Provider. Active Duty Service Members (ADSMs) are not eligible for these initial eight, self-referred visits. ADSMs must always receive a referral from their Primary Care Manager (PCM) for civilian services before seeking care outside a military treatment facility (MTF).

It is important to note that TRICARE policy states that pastoral counselors, mental health counselors, and licensed professional counselors always require an MD, DO, or psychiatrist referral, even for the initial eight self-referred visits. The beneficiary must take this referral with them to the provider’s office upon the first visit. According to TRICARE policy, the provider must have this referral in the beneficiary’s record and must indicate this information on the claims submitted by the provider. Prime beneficiaries should always utilize network providers for reduced cost shares.

As noted on the PAL, other than the initial eight self referred visits, all other outpatient behavioral health services require prior authorization. Frequently, the use of CPT codes 90808 and 90809 are misunderstood. These CPT codes do not fall under the "routine" outpatient behavioral health visits for TRICARE; therefore they are not included in the initial eight self-referred visits. The 2007 CPT manual defines CPT codes 90808 and 90809 as sessions "…approximately 75-80 minutes face to face with the patient." The TRICARE Policy Manual further defines these codes as "crisis intervention" codes (refer to TRICARE Policy Manual 6010.54 M, August 1, 2002, Chapter 7, Section 3.13, IVA2.)

When a provider determines that a 90808 or 90809 is appropriate, a Preauthorization for Outpatient Treatment Request form must be completed and faxed to TriWest for authorization. This can be done after the session is completed due to the nature of a "crisis intervention."

For "routine" behavioral health visits (e.g., CPT codes 90804, 90805, 90806, 90807, 90846, and 90847) after the initial eight self-referred visits, the Preauthorization for Outpatient Treatment Request form must be completed prior to the initiation of services.

The Behavioral Health web portal on www.triwest.com has information regarding behavioral health benefits as well as evidence-based clinical practice guidelines, printable patient resources, and many tools that TRICARE providers may find helpful. Or providers can call us at 1-888-TRIWEST (888-874-9378).