Documentation for Tricare Clients

Working with All Tricare Clients

In accordance with Chapter 7, Section 6 of the TRICARE Operations Manual, TRICARE network behavioral health providers and facilities are required to track and document specific outcome measures during patient visits. This requirement applies across all behavioral health care settings and helps support both quality care and program compliance.

Required Timing for Outcome Measures

For patients with post-traumatic stress disorder (PTSD), an anxiety disorder, or a depressive disorder, standardized outcome measures must be administered at treatment baseline, at discharge, and every 60 days during treatment.

• Posttraumatic Stress Disorder -- PSTD Checklist (PCL-5)
• Anxiety Disorders - Generalized Anxiety Disorder screen (GAD-7)
• Depressive Disorders-Patient Health Questionnaire: PHQ-9; PHQ-9 modified for Adolescents (PHQ-A)

Importance of Outcome Measures

Using these standardized tools regularly helps providers:

• Support efficient history-taking, documentation, and treatment planning
• Assess patient progress overtime
• Give patients a clear way to visualize their improvement

Working with Tricare PRIME - Active Duty

A referral from Tricare is required when working with Tricare Prime Active Duty clients when the actual active duty member is the IP.  No referral is needed for Tricare Select Active Duty, retired service members, or the spouse of a Tricare Prime Active Duty member. The Support Team usually collects and adds the referral to the client’s file before the intake. The referral lists the number of sessions allowed and the client’s Military Treatment Facility (MTF) to which the clinician must report.  

Send Treatment Summary to Tricare MTF Facility

No more than 7 days after the intake appointment AND after discharge, clinicians are required to fax a treatment summary/discharge to the MTF.  If the MTF calls you at any given moment during treatment, you’ll need to send a treatment summary to them ASAP.

• Use the “Treatment Summary - Tricare Prime Active Duty” template in the Template Gallery.  The last four digits of the SSN are in the Referral doc.
• ROI is NOT needed - HIPAA guidelines do not apply.
• You can explain to your client that this is a requirement.  

MTFs in Colorado