Table of Contents

What is a request type?

Request types are templates created for use with Health Net Federal Services, LLC's (HNFS) online referral and authorization submission tools, available at tricare- > Provider. Each request type has been developed by HNFS in accordance with the TRICARE manuals. When a request type is selected, the associated codes/code ranges, number of visits, and duration of the authorization will pre-populate on the request.

Table of Contents

Outpatient Specialty Referral ..................................................................................................... 2 Outpatient Authorizations

Physical Health ...................................................................................................................... 3 Behavioral Health................................................................................................................... 5 Durable Medical Equipment ....................................................................................................... 6 Inpatient Authorizations ............................................................................................................. 7

TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Up dated 05/04/23. HH0618x013 (05/23)

1

Outpatient Specialty Referral Request Types

Description Evaluate and Treat Specialty Referral Evaluate Only Specialty Referral

Included CPT? Code(s)

Request Type

99202?99205, 99211?99215, 99242?99245 P1

Approval Duration

180 days for ADSMs 365 days for nonADSMs

99202?99205, 99211?99215, 99242?99245 P3

180 days

Oncology ? Evaluate and Treat Spec Ref

99202?99205, 99211?99215, 99242?99245 P6

Pre/Post Transplant

99211?99215, 99242?99245

P58

Routine Eye Examination Second Opinion Specialty Referral Extension

92002?92015

P63

99202?99205, 99211?99215, 99242?99245 P5

99211?99215

P4

ADSMs = active duty service members

Request types, descriptions and corresponding codes are subject to change.

365 days 360 days for codes 99211?99215 90 days for codes 99242?99245

90 days

90 days

180 days, dependent on initial episode of care date

2

Outpatient Authorization Request Types

Physical Health

The Approval Duration column shows HNFS' standard authorization time frames. However, if the PCM's specialty referral is still valid (see p.2 for referral durations), servicing providers should request a date extension using the online Authorization Change Request Form rather than asking the PCM for a new referral. (Exception: For physical, speech and occupational therapy, and applied behavior analysis [ABA] and Extended Care Health Option [ECHO] services, please submit a new authorization request to HNFS.)

Description

ACD ABA Initial Assessment Authorization ACD Outcome Measure Authorization ACD ABA Treatment Authorization

ACD ABA Discharge Report Submission Acupuncture Adjunctive Dental* Air Ambulance Services Allergy Services Ambulance Services Audiology Breastfeeding Counseling Cardiac Rehabilitation Chiropractic Care Colonoscopy Custodial Care Home Dental Anesthesia Dental/Adjunctive Dental Svc Data Entry Diabetic Education Diabetic Eye Exam Dialysis

Emergency Room Visit

Global OB Global OB ICD-10 Hippotherapy

Home Health Infusion Therapy*

Home Health Basic Benefit Under PPS Hospice Hourly Skilled Nursing Injection, Epidural (Cervical or Thoracic) Injection, Epidural (Lumbar or Sacral) Injection, Facet Joint (Cervical or Thoracic) Injection, Facet Joint (Lumbar or Sacral) Injection, HPV Integrated Disability Evaluation Maternity Ultrasounds Non-USFDA LDTs Demo* Nutritional Counseling Observation Stay

Included CPT?, NDC, HCPCS Codes

Request Type

97151

P174

97151, 97151, 97151

P175

97151, 97153, 97155, 97156, 97157, 97158, P177 99366, 99368

99199

P178

97810

P163

*generic request type (enter codes manually) P127

A0430?A0431

P116

95004, 95017?95117

P9

A0999

P10

92550, 92552?92557, 92563?92584, 92588 P11

99401?99404

P159

93797?93798

P12

98940?98943

P14

45300?45392

P43

99600

P165

41899, 00170

P101

D9310, 992202?92205, 99242?99245

P22

G0108?G0109

P23

92082, 92250, 99203?99204

P114

90935

P60

99281?99285

P44

59400?59622

P76

59400?59622

P126

S8940

P124

99601?99602 *generic request type (can also enter codes P28 manually)

0023

P26

0651?0657, 0551, 0561, 0571

P46A

99347

P48

62320?62321, 77003

P30

62322?62323, 77003

P31

64490?64492

P32

64493?64495

P33

90649

P29

99456

P111

76801?76817

P34

*generic request type (enter codes manually) P162

97802?97804

P24

G0378?G0379

P35

Approval Duration

45 days 365 days 180 days

1 day 90 days 180 days 14 days 180 days 14 days 90 days 180 days 90 days 90 days 90 days 30 days 180 days 180 days 180 days 90 days 90 days 5 days after and 15 days prior to the date of service 11 months 11 months 180 days 90 days for codes 99601?99602 180 days for all others 60 days 90 days 90 days 90 days 90 days 90 days 90 days 180 days 180 days 90 days 60 days 180 days 10 days

3

Occupational Therapy ? Acute Injuries

Occupational Therapy ? Post Op Care

Occupational Therapy ? Long Term Conditions Opioid Replacement Therapy (ORT) Osteopathic Manipulation Outpatient Infusion Therapy or Medication Administration*

97165, 97167?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97165, 97167?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97165, 97167?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 7535

0912?0913

98925?98929

P36A

P36B

P36C P152 P37

*generic request type (enter codes manually) P115

120 days

150 days

180 days 180 days 90 days 90 days

Outpatient PH Medical Procedure*

*generic request type (enter codes manually) P106

180 days

Outpatient PH Surgical Procedure*

Physical and Occupational Therapy ? Acute Injuries

Physical and Occupational Therapy ? Post-Op Care

Physical and Occupational Therapy ? Long-Term Conditions

Physical Therapy ? Acute Injuries

Physical Therapy ? Post-Op Care

Physical Therapy ? Long-Term Conditions Pulmonary Rehabilitation Pulmonary Rehabilitation Pre/Post Transplant Respite Care for Extended Care Health Option

*generic request type (enter codes manually) P105

97165?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 97161?97164, 97010, 97016-97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97165?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 97161?97164, 97010, 97016-97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97165?97168, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 97161?97164, 97010, 97016-97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97161?97164, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

97161?97164, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852,97530, 97535

97161?97164, 97010, 97016?97024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535

P125A

P125B

P125C P38A P38B P38C

G0237?G0238

P13

97161?97163, 97110

P59

99600

P47

180 days 120 days

150 days

180 days

120 days 150 days 180 days 90 days 30 days for codes 97161?97163 90 days for code 97110 365 days

Sleep Study Sleep Study (Under 6 Years Old)

95810?95811 95782?95783

P40 P123

90 days 90 days

Smoking Cessation Speech Therapy ? Acute Injuries Speech Therapy ? Post-Op Care Speech Therapy ? Long-Term Conditions Synagis

Terminal Leave Blanket Authorization

Trigger Point Injections Urgent Care *= generic request type

96156, 96158?96159, 96164?96165 92521?92524, 92507 92521?92524, 92507 92521?92524, 92507, 92610 90378

P62 P39A P39B P39C P67

99202?99215, 90791?90792, 99202?99205 P128

20552?20553

P41

99202?99205

P45

120 days 120 days 150 days 180 days 150 days This request type is to be used by military hospitals or clinics only 90 days 5 days after and 15 days prior to the date of service

4

Outpatient Authorization Request Types (continued)

Behavioral Health

The Approval Duration column shows HNFS' standard authorization time frames. However, if the PCM's specialty referral is still valid (see p. 2 for referral durations), servicing providers should request a date extension using the online Authorization Change Request Form rather than asking the PCM for a new referral.

Description

Outpatient Therapy (BH)

Included CPT?, NDC, HCPCS Codes

Request Type

90791?90792, 90832?90840, 90846?90853, 99211?99215, 90785, 99202?99205

P50

Electroconvulsive Therapy (BH)

90791?90792, 90870

P64

IOP Psych (BH) IOP Substance Abuse (BH) Medication Assistant Treatment (BH)* Medication Management (BH) Observation Stay (BH) PHP Psych Full Day (BH) PHP Psych Half Day (BH) PHP Substance Abuse Full Day (BH) PHP Substance Abuse Half Day (BH)

S9480 H0015 *generic request type (enter codes manually) 99202?99215 G0379 0913 0912 0913 0912

P156 P157 P167 P51 P75 P71 P73 P72 P74

Psychological/Neuropsychological Testing (BH)

90791?90792, 96130?96146

P171

Sparvato? Esketamine (BH)

G2082?G2083

P173

Transcranial Magnetic Stimulation (BH)

90791?90792, 90867?90869

BH = behavioral health, *= generic request type

P166

Approval Duration

90 days for codes 90791?90792, 99202?99205 180 days for codes 90832? 90840, 90846?90853, 99211?99215, 90785 90 days for codes 90791?90792 180 days for code 90870 90 days

90 days

180 days

180 days

10 days

90 days

90 days

90 days

90 days 90 days for codes 90791?90792 180 days for codes 96130?96146

90 days

90 days for codes 90791?90792 365 days for codes 90867?90869

5

Durable Medical Equipment Request Types

The Approval Duration column shows HNFS' standard authorization time frames. However, if the PCM referral is still valid (see p. 2 for referral durations), servicing providers may request a date extension using the online Authorization Change Request Form rather than going back to the PCM for a new referral.

Description

ASV (Adaptive Servo-Ventilation Machine) Purchase and Supplies ASV Rental and Supplies BiPap Purchase and Supplies BiPap Rental and Supplies

Breast Pump and Supplies ? Heavy Duty Hospital Grade

Breastfeeding Pump and Supplies Commode (3 in 1) CPAP Standard Purchase and Supplies CPAP Standard Rental and Supplies

CPAP Portable Purchase and Supplies

CPAP Portable Rental and Supplies

CPAP Supplies Only CPM Machine ? Knee CPM Machine ? Other DME Purchase and Med Supplies Generic (Outpatient)* DME Rental and Med Supplies Generic (Outpatient)* Insulin Pump Purchase and Pump Supplies Insulin Pump Rental and Pump Supplies LVAD Personal Incontinence Supplies Prosthetics and Orthotics Generic (Outpatient)* Rolling Walker Synthetic Sheepskin Pad TENS Unit ? Purchase TENS Unit ? Rental Wheelchair Rental ? Basic Wound Vacuum *= generic request type

Included CPT?, NDC, HCPCS Codes

E0471, E0562, A7027?A7039, A7046, A4604 E0471, E0562, A7027?A7039, A7046, A4604 E0562, E0470, A7030?A7039, A7046 E0562, E0470, A7030?A7039, A7046

E0604, A4281?A4286, A9999, A9900

E0602?E0603, A4281?A4286, A9999, A9900 E0163 E0601, E0562, A7027-A7039, A7046, A4604, E0601, E0562, A7027?A7039, A7046, A4604 E0601, E0562, E1399, A7027?A7039, A7046, A4604 E0601, E0562, E1399, A7027?A7039, A7046, A4604 A7027?A7039, A7046, A4604 E0935 E0936

*generic request type (enter codes manually)

*generic request type (enter codes manually)

E0784, A4222, A4231-A4232 E0784, A4222, A4231-A4232 L9900 A4520, T4521?T4536, T4539, T4543

*generic request type (enter codes manually)

E0143 E0188 E0720?E0730, A4595, E0731 E0720?E0730, A4595, E0731 K0001, E0990 E2402, A6550, A7000, A4221, A4222

Request Type

P168P P168R P17P P17R

P160

P158 P57 P16P P16R P172P

P172R P155 P54 P65

P108

P107

P15P P15R P61 P161 P109 P56 P55 P113 P112 P18 P21

Approval Duration

455 days 455 days 455 days 455 days 90 days for codes E0604 455 days for codes A4281-A4286, A9999, A9900 455 days 455 days 455 days 455 days 455 days

455 days 455 days 21 days 21 days

455 days

455 days

455 days

455 days 455 days 365 days

180 days

455 days 455 days 455 days 455 days 455 days 180 days

6

Inpatient Authorization Request Types

For use with CareAffiliate? only. The Web Authorization/Referral Form (WARF) does not support inpatient requests.

Description

Included CPT?, NDC, HCPCS Codes

Bariatric Surgery Laparoscopic Roux-en-Y (Inpatient PH) Bariatric Surgery Laproscopic Banding (Inpatient PH) Bariatric Surgery Open Roux-en-Y (Inpatient PH) Bariatric Surgery Vertical Banding (Inpatient PH) BH Admit (Inpatient) Chemical Dependency (BH CD) ? Detoxification Chemical Dependency (BH CD) ? Rehabilitation C-Section Delivery (Inpatient)

Custodial Care (Inpatient)

Double Lung Transplant (Inpatient PH )

Heart Lung Transplant (Inpatient PH)

Heart Transplant (Inpatient PH)

Intestinal Transplant (Inpatient PH)

Islet Cell Transplant (Inpatient PH)

43644

43770?43774

43846

43842 99221 99221

99221 59514 99324 32852?32584 33935 33945 44135?44136 48160

Kidney Transplant (Inpatient PH)

50360, 50365, 50380

Liver Transplant (Inpatient PH)

47135?47136

Long Term Acute Care (Inpatient PH)

99221

Medical Admit (Inpatient PH)

99221

Pancreas Transplant (Inpatient PH)

48554

Rehabilitation ? Acute (Inpatient PH)

99221

Residential Treatment Center (BH Inpatient) 99221

Single Lung Transplant (Inpatient PH)

32851

Skilled Care (Inpatient PH)

Stem Cell Transplant Allogeneic (Inpatient PH) Stem Cell Transplant Autologous (Inpatient PH)

Surgical Admit (Inpatient PH)*

0022 38240 38241 *generic request type (enter codes manually)

Vaginal Delivery (Inpatient)

59409

BH = behavioral health, PH = physical health, *= generic request type

Request Type

P97

P98

P100

P99 P81 P83

P84 P80 P164 P89 P90 P94 P93 P92 P86 P87 P104 P77 P91 P103 P82 P88 P102 P95

P96 P78 P79

Approval Duration

30 days

30 days

30 days

30 days 5 days 7 days

5 days 180 days 30 days 365 days 365 days 365 days 365 days 365 days 355 for code 50360 365 for code 50365, 50380 365 days 30 days 5 days 365 days 30 days 5 days 365 days 30 days 365 days

365 days 30 days 180 days

7

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