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TRICARE East RTC Concurrent Review Form

TRICARE covers psychiatric residential treatment center (RTC) care for beneficiaries under 21 with a primary behavioral health diagnosis, and Humana Military reviews each continued stay with this seven-page form. The RTC's rendering provider updates diagnoses, medications, mental status, current symptoms and safety precautions, treatment plan revisions, family therapy and the discharge plan, and explains why a step-down level of care is not yet appropriate.

Who completes it

The RTC's attending or rendering provider completes the whole form and signs it, attesting that treatment is necessary and not feasible at a lower level of care.

Submitting and payment

How to submit it
Type it in the fillable fields rather than by hand and submit it through Humana Military provider self-service; fax only if online submission is not possible.
Who pays
TRICARE Policy Manual Chapter 11, Section 2.9 makes RTC care a benefit only for beneficiaries under age 21 with a primary behavioral health diagnosis.

Good to know

  • Substance use disorder residential treatment does not use this form; Humana directs those requests to the inpatient authorization form to avoid delays or denials.
  • The rendering provider attests that the parent or guardian will actively participate in family therapy and continuing care unless therapeutically contraindicated.
  • The form asks for family therapy dates, method, frequency and measurable goals, plus the family's expectations, including where the child will live after treatment.
  • Discharge planning lists step-down options such as PHP, IOP, outpatient therapy, psychiatry, ABA and primary care, plus 504 plan or IEP education supports.

Get the official form

Download the current version from the source each time; forms change without notice.

Residential Treatment Center (RTC) form concurrent review

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who qualifies for TRICARE residential treatment center care?

TRICARE Policy Manual Chapter 11, Section 2.9 defines RTC treatment as a benefit for beneficiaries under 21 with a behavioral health primary diagnosis. Both facts are answered yes or no at the top of the concurrent review form, and substance use disorder residential care follows a different form.

What does Humana Military look for in an RTC concurrent review?

Current symptoms with specific examples, safety checks or precautions, response to interventions and progress; treatment plan revisions where goals were not met; updated medical diagnoses and labs; family therapy details; and clinical justification for continued residential care rather than a step-down level.

What does the provider attest by signing the RTC concurrent review?

That the recommended treatment is necessary, appropriate and not feasible at a lower level of care, or that lower level efforts were exhausted; that the patient can participate in and respond to therapy; and that the parent or guardian will take part in family therapy unless contraindicated.