Humana Military Healthcare Services (HMHS) was awarded the managed care support contract for the TRICARE South Region. HMHS handles all medical and surgical issues. HMHS has subcontracted all mental health and substance use issues to ValueOptions and subcontracted with PGBA to be the fiscal intermediary for claims payment. HMHS is known as the Prime Contractor and ValueOptions and PGBA are subcontractors. Together, we work as a team to provide you, the beneficiary, the highest quality services.
You may contact HMHS’ beneficiary services by calling 1-800-444-5445 and ValueOptions at 1-800-700-8646. For claims issues please contact PGBA at 1-800-403-3950.
The MTF or the Military Medical Support Office (MMSO) will initiate referral/authorization requests for ADSMs and other designated patients to civilian specialists and sub-specialists for services that are beyond the scope of services available at the MTF. A DD Form 2161 (this form may vary by MTF site) will be completed and sent to Humana Military prior to sending the patient for behavioral health treatment. ValueOptions and the MTF, as appropriate, will agree on a civilian provider to administer the care; ValueOptions then processes the authorization and notifies the patient and provider of the authorization for care. Again, a MTF referral is only required for ADSMs.
Behavioral health evaluation and therapy benefits are limited to two routine therapy sessions per week; more frequent visits require additional authorization.
Substance use disorder benefits are limited to 60 group therapy sessions and 15 family therapy sessions per benefit period. Individual outpatient therapy is not a covered benefit for beneficiaries with a primary diagnosis of substance use disorder. The benefit period begins with the first day of a treatment episode and ends 365 days later, regardless of the total services actually used within the year. Services must be rendered by institutional providers and always require prior authorization.
Psychological testing is generally limited to six hours per year and requires a medical necessity review and prior authorization.
Behavioral health benefits are limited to 30 days per fiscal year or per admission for acute inpatient care for ages 19 and older; and 45 days per fiscal year or per admission for acute inpatient care for ages under 19.
Benefits are limited to 150 days per fiscal year or per admission for care in TRICARE approved Residential Treatment Centers
Substance Use Disorder Rehabilitation benefits are limited to 21 days per benefit period (combined with partial and/or inpatient). The benefit period begins the first day of covered treatment and ends 365 days later. Days count toward the 30 or 45 day mental health inpatient limits.
All partial hospitalization services require medical necessity review and prior authorization, and must consist of a minimum of three hours of therapeutic services, up to five days per week may be authorized. Behavioral health disorder benefits are limited to 60 treatment days per fiscal year, and are not offset by or counted toward the 30 or 45 day inpatient limit. Care must be provided in a TRICARE-authorized/certified mental health partial hospitalization program.
LCSW - Licensed Clinical Social Worker. Masters Degreed Therapist licensed to practice therapy. May focus on areas such as Child Therapy, Adolescents, Family Therapy, etc.
LMHC - Licensed Mental Health Counselor. Masters Degreed Therapist licensed to practice therapy. May focus on areas such as Child Therapy, Adolescents, Family Therapy, etc. Requires Letter of Referral and oversight from M.D. or D.O.
LPC - Licensed Professional Counselor or Licensed Pastoral Counselor. Masters Degreed Therapist licensed to practice therapy. May focus on areas such as Child Therapy, Adolescents, Family Therapy, etc. Requires Letter of Referral and oversight from M.D. or D.O.
LMFT - Licensed Marriage and Family Therapist. Masters Degreed Therapist licensed to practice therapy. May focus on areas such as Child Therapy, Adolescents, Family Therapy, etc.
Ph.D. - Psychologist. Have Masters Degree and a Doctoral Degree in Clinical Psychology. Have license to practice therapy. Most do testing, some offer therapy.
M.D. or D.O. - Psychiatrist. Medical Doctor. Prescribes medication, can do therapy.
RNCS - Registered Nurse Clinical Specialist. Can provide therapy. In some states can prescribe medication.
ARNP - Advanced Registered Nurse Practitioner. In most states, can prescribe medication with oversight from M.D. Can provide therapy.
Active duty family members (ADFMs), retirees and retiree family members (Prime and Standard) can self-refer for routine outpatient mental health treatment. A PCM referral is not required for non-ADSM Prime beneficiaries. The first eight (8) visits per fiscal year for these beneficiaries (Prime and Standard ADFMs, retirees and retiree family members) do not require an authorization for claims to pay. After the 8th visit, an authorization is required from ValueOptions.
However, active duty service members (ADSMs) cannot self-refer for behavioral health services. ADSMs must always obtain prior authorization from their PCM for all behavioral health care.
If the provider rendering services is an LPC, LMHC, or a pastoral counselor, TRICARE policy requires a physician referral prior to the initial evaluation, which must be submitted with the initial claim. Oversight must continue throughout the course of therapy in order to be reimbursed by TRICARE. The ValueOptions “Letter of Referral” form was created exclusively for this requirement, for claims payment purposes. LPCs, LMHCs, and Pastoral Counselors are responsible for obtaining their own physician referral and oversight prior to rendering services to any TRICARE beneficiary. The PCM may elect, but is not required, to provide the referral and/or oversight when referring to these providers.
Yes. For mental health or substance use services, the POS option is determined by the network status of the provider. TRICARE Prime beneficiaries who choose a non-network provider for their mental health or substance use services will be responsible for the increased POS cost shares. To verify the network status of the provider you wish to see, call 1-800-700-8646. The only exception to the preauthorization requirement for mental health or substance use services is the first eight outpatient mental health visits (does not include psychological testing). Prime beneficiaries must still see a network provider for the first eight visits or the POS option will apply.
In an emergency, call 911, your local emergency number, or go to the nearest hospital emergency room. If you are admitted, you, a family member, or your provider must contact ValueOptions within 24 hours to obtain an authorization.
Although referrals from your doctor are welcome, they are not required. You can call 1-800-700-8646 to access mental health or substance use services directly.
All records and services are kept and provided with the strictest confidence. Staff members sign confidentiality statements as a condition of employment and receive training on this important issue. Network providers are bound by their contract to maintain confidentiality. The personal information you share is completely confidential unless you sign a release form or if the law requires disclosure.
Your network provider must file a claim on your behalf. If your non-network mental health provider does not file a claim on your behalf, you may mail your claim to:
TRICARE Behavioral Health
South Region Claims
P.O. Box 7034
Camden, SC 29020-7034
For questions regarding claims, please contact PGBA at 1-800-403-3950.
