The Process of Getting Approval From Tricare for Going to a Philadelphia Rehabs Alcohol Treatment Center

Tricare is the official healthcare program offered to military personnel, their spouses, and their dependents. Tricare not only covers active duty personnel but also retired members of the Army, Marine Corps, Navy, Air Force, Coast Guard, the US Public Health Service, and the Commission Core. Tricare offers a range of benefits including health plans, dental plans, prescriptions, and special programs.

Like most insurance companies, the process of getting approval for treatment can seem overwhelming and unwieldy. Fortunately, you can break the approval process into step-by-step pieces. If you or a loved one need to go to an alcohol treatment center, you have enough on your mind without worrying about piles of paperwork.

Tricare’s Substance Abuse Coverage

Tricare does offer a range of services for substance abuse and alcohol abuse treatment. This includes emergency hospitalization services, management of medical detox, and residential substance abuse treatment services. These are all the things you may need covered should you seek treatment for an alcohol abuse disorder.

To utilize Tricare’s substance abuse coverage, however, you’ll need to prove that the treatment is a medical necessity. A medical necessity is defined as the healthcare services and treatment methods which are necessary to diagnose and treat a disease or underlying condition.

The easiest part will be making the case that treatment is a medical necessity. Alcohol use disorders count as a mental health problem and a disability. Mental health issues are defined as medical conditions by law. The approved treatment for a substance abuse disorder is detoxification and mental health treatment.

You might need to provide additional documentation to prove that an inpatient rehab is necessary, though. This will mean proving that outpatient services aren’t extensive enough for your circumstances. It’s also likely that Tricare will dispute additional services that aren’t medically necessary — if you opt into a laundry service in a rehab center, for example.

Tricare will only cover treatments that have been approved by the FDA or otherwise medically proven. The insurance company will not cover experimental treatments, even if a physician officially orders them.

Choosing a Treatment Facility

Before you settle on any kind of treatment, you’ll need to make sure it’s covered by Tricare. You should call your Tricare customer service representative with the information about your case. The customer service representative will not be able to make a decision regarding your claim, but they will be able to tell you if the treatment center will be covered should you receive approval.

For example, you might choose a Philadelphia Rehabs treatment center and call the customer service line to ask if Tricare covers treatment there. If the answer is no, all the documentation in the world won’t matter because Tricare will not cover that facility’s treatments. However, if the answer is yes, you can go about amassing the necessary medical documentation to prove your medical necessity.

You’ll have to follow the same method for intensive outpatient services. Oftentimes, alcohol treatment centers will offer a range of outpatient services as well as inpatient services. If you find a center you like, you can sign up for their outpatient services while you wait for approval for residential treatment.

What Documentation Do I Need for Approval?

As previously stated, you’ll need to prove that residential treatment at a Philadelphia Rehabs alcohol treatment center is a medical necessity. But how can you do that? You’ll have to follow these steps:

  • Call the Tricare customer service department to make sure the treatment center of your choice is covered by Tricare
  • Visit a psychiatrist and get a formal diagnosis of a mental health condition other than a substance abuse disorder, because this is necessary for Tricare to cover a residential treatment plan
  • Receive a formal referral from your psychiatrist or physician for alcohol rehabilitation treatment

In most cases, the qualification for medical necessity is met when a physician documents a formal referral. Note, however, that the case may be disputed if an individual other than a physician files the claim. This means that your psychiatrist can file the claim, but a counselor who hasn’t gone to medical school cannot.

If your rehab referral doesn’t come from a physician, you can make a request for a physician to be part of your formal intake evaluation. If the physician recommends rehabilitation services during the intake process, this can count as proof of medical necessity.

It’s very important that you call the customer service line and check that your rehab center of choice is covered. You should do this before you sign up for any residential or outpatient treatment plans. If you sign up with a treatment center that is not approved by Tricare, you could find yourself in the middle of a paperwork headache at best and paying thousands of dollars out-of-pocket at worst.

How to Get the Physician Recommendation

Your physician will write a formal recommendation for you to enter an alcohol treatment center if it’s clear that outpatient services will not be enough to upkeep your sobriety and prevent future relapses. Any of the following criteria might count:

  • Your living environment has multiple substance use triggers
  • You’ve established a pattern of relapsing already
  • You cannot handle day-to-day life and require a more stable environment
  • You require more specialized mental health treatment than outpatient services alone can provide

In the end, it helps to be honest with your doctor. Explain why you feel you need to enroll in an alcohol treatment center. Emphasize that you’re trying to get help and better your life, but that you aren’t sure whether outpatient services will be enough. If you’ve ever been to a treatment center, telling your doctor about your experience may also help.

If you have any questions regarding health insurance policies or substance abuse treatment, please call 800-723-7376 to speak to one of our trained counselors. It’s never too early to be proactive about your mental health treatment.