Behavioral Health TRICARE South Contract

1. Behavioral HealthTRICARE South Contract Federal Division ValueOptions

2. ValueOptions-TRICARE Central Office: Jacksonville, Florida Market Office: Augusta, Georgia Strictly Dedicated to TRICARE Member of the HMHS team since 1996 Access through TRICARE 800-874-2273, HMHS 800-444-5445 or direct ValueOptions toll free number (800-700-8646) for Customer Service, UM, Appeals, QI, Field Support, Provider Relations, Credentialing, Administration E-Mail: firstname.lastname@jax.valueoptions.com BH information available on HMHS website (www.humana-military.com)

3. Key Departments-Jacksonville Call 1-800-700-8646 to contact: Administration Lucy Buckner, Executive Director, ext. 2063 Customer Service Roxane Kissinger, CS Director, ext. 2055 Mike Peters, CS Manager, ext. 2071 Utilization Management Gary Proctor, MD, Chief Medical Officer, ext. 2065 Debbie Mattingly, UM Manager, ext. 2163 Quality Improvement/Credentialing/Grievances Robin McBride, QI Director, ext. 2062 Provider Relations Kim Hepler, PR Director, ext. 2102

4. Correspondence ValueOptions-TRICARE PO Box 551188 Jacksonville, FL 32255

5. Field Offices (Market Offices)

6. Behavioral Health Benefit Routine Outpatient Care (up to twice per week) Inpatient Care (up to 30/45 days per fiscal year) Substance use rehabilitation based on 365 day year (one per year, 3 per lifetime) RTC (up to 150 days per fiscal year) PHP (up to 60 days per fiscal year) Substance Abuse (up to 21 days per treatment) (All these limits are based on medical necessity and are subject to waiver in special circumstances)

7. Preauthorization Requirements Outpatient visits after the unmanaged 8 Psychological/Neuropsychological testing for BH diagnoses Inpatient (detoxification, psychiatric and substance abuse rehabilitation) RTC and PHP levels of care Psychoanalysis Outpatient ECT

8. Outpatient Care Beneficiaries may self refer First 8 mental health visits per beneficiary per fiscal year do not require preauthorization or referral Visits from 9 forward require authorization, but not referral ValueOptions utilizes outlier management of outpatient care for authorization of visits, based on diagnosis

9. Outpatient Care (continued) Federal Regulation requires Licensed Mental Health Counselors, Professional Counselors and Pastoral Counselors obtain physician referral and oversight. Physician evaluation and referral must include diagnosis and must be completed prior to being seen by the LMHC/LPC/PC. MTF can elect to provide this referral/oversight or ValueOptions will make referral to a network psychiatrist/physician

10. Outpatient Treatment Report Necessary for authorization for visits 9 onward Medication Management (CPT 90862) does not need an OTR Newly revised, concise (1 page) Available on HMHS Website under the BH section

11. Inpatient Care Can include detoxification, acute psychiatric stabilization or substance use rehabilitation Must be preauthorized, or authorized within 72 hours if an emergency Allow telephonic or fax reviews (preferred) For stabilization of a life threatening emergency (32CFR199.4.b) Not for runaway behavior (32CFR199.4.g)

12. Residential Treatment Benefit is for Children and Adolescents only Must be preauthorized Is not an emergency per TRICARE Policy RTC written application available on website Admission primarily for substance abuse is not a benefit Family therapy required unless contraindicated (may be telephonic if geographically distant)

13. Partial Hospitalization Chemical Dependency or Psychiatric Full day or half day Psych PHPs must be NQMC Certified Is not an emergency per TRICARE policy

14. MTF Referrals to MCSC for BH Referrals for Behavioral Health are faxed to HMHS HMHS begins process and determines which cases are BH and forward to ValueOptions ValueOptions processes, determines medical necessity and sends out determinations to provider, beneficiary and MTF POC Extended sessions beyond initial referral are completed according to best business practices (in accordance with TOM Chapter 8, Section 5, 7.2.1.6)

15. Exclusions Biofeedback for BH diagnoses Individual therapy for a primary Substance Abuse Disorder Psychological testing for Learning Disorders Sensory Integration Therapy for sexual dysfunctions Therapy for weight loss or smoking cessation programs/services

16. Supplemental HealthCare/TPR Active Duty are not allowed to self refer POC for ValueOptions (1-800-700-8646) Kim Lewis (primary) ext. 2014 Deborah Hallman (secondary) ext. 2006 Fax (SHCP) 866-811-4422 All SHCP coordinated with MTF All TPR coordinated with SPOC

17. First Right of Refusal/NAS For cases that are subject to the ROFR, VO follows the same mechanism as HMHS Based on available services indicated in MTF MOU supplements NAS still required for BH admissions for non-emergency cases for non-enrolled beneficiaries in catchment areas Beneficiary�s responsibility to obtain NAS

18. Consult Returns BH consult returns follow the same process as medical/surgical consults Self referred care is not applicable to the consult return requirement, however, providers are strongly encouraged to communicate with PCM Consult returns are forwarded to the MTF POC in accordance with HMHS processes

19. Provider Relations/Networks VO is aggressively recruiting and credentialing providers in areas of need Continue to credential new providers Any specific issues/hot spots should be referred to Provider Relations at the toll free number 800-700-8646 (option 4)

20. Medicare Dual Eligibles For all Medicare eligibles (under and over 65 years of age) Wisconsin Physician Services (TDEFIC Fiscal Intermediary) Only limited requirements for authorization ValueOptions completes authorizations for inpatient care over 30 days per fiscal year and when Medicare inpatient benefit has been exhausted; coordinating with WPS

21. Appeals and Reconsiderations Completed by Board Certified Psychiatrists with active practices in the Region Expedited/non-Expedited Must be requested in writing ValueOptions TRICARE Appeals and Reconsiderations PO Box 551138 Jacksonville, FL 32255 vorecon@jax.valueoptions.com

22. Case Management Referrals can be made by providers, the beneficiaries themselves, MTFs etc. A BH case management referral form is available (along with HMHS referral forms) on the HMHS website