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 Updated 02/02/21. HH0618x013 (06/21)
1
Outpatient Specialty Referral Request Types
Description Evaluate and Treat Specialty Referral Evaluate Only Specialty Referral
Included CPT? Code(s) 99202?99205, 99211?99215, 99241?99245
Request Type
P1
Approval Duration
180 days for ADSMs 365 days for nonADSMs
99202?99205, 99211?99215, 99241?99245 P3
180 days
Oncology ? Evaluate and Treat Spec Ref
99202?99205, 99211?99215, 99241?99245 P6
Pre/Post Transplant
99211?99215, 99241?99245
P58
Routine Eye Examination Second Opinion Specialty Referral Extension
92002?92015
P63
99202?99205, 99211?99215, 99241?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 99241?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, 99241?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, G0270?G0271
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 90 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* Outpatient PH Medical Procedure*
97165, 97167?97168, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
97165, 97167?97168, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
97165, 97167?97168, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
0912?0913
98925?98929
P36A
P36B
P36C P152 P37
*generic request type (enter codes manually) P115
*generic request type (enter codes manually) P106
120 days
150 days
180 days 180 days 90 days 90 days 180 days
Outpatient PH Surgical Procedure*
*generic request type (enter codes manually) P105
180 days
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
97165?97168, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 97161?97164, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
97165?97168, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 97161?97164, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
97165?97168, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 97161?97164, 97010?97012, 9701697024, 97028, 97033?97036, 97110?97124, 97140?97150, 95851?95852, 97530, 97535
97161?97164, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 95851?95852, 97530, 97535
97161?97164, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 95851?95852,97530, 97535
P125A P125B P125C P38A P38B
120 days 150 days 180 days 120 days 150 days
Physical Therapy ? Long-Term Conditions
97161?97164, 97010?97012, 97016?97024, 97028, 97033?97036, 97110?97124, 97140? 97150, 95851?95852,97530, 97535
P38C
180 days
Pulmonary Rehabilitation
G0237?G0238
P13
90 days
Pulmonary Rehabilitation Pre/Post Transplant
97161?97163, 97110
30 days for codes
P59
97161?97163
90 days for code 97110
Respite Care for Extended Care Health Option
99600
P47
365 days
Sleep Study
95810?95811
P40
90 days
Sleep Study (Under 6 Years Old)
95782?95783
P123
90 days
Smoking Cessation
96156, 96158-96159, 96164-96165
P62
120 days
Speech Therapy ? Acute Injuries
92521?92524, 92507
P39A
120 days
Speech Therapy ? Post-Op Care
92521?92524, 92507
P39B
150 days
Speech Therapy ? Long-Term Conditions
92521?92524, 92507, 92610
P39C
180 days
Synagis Terminal Leave Blanket Authorization
90378
P67
99202?99215, 90791?90792, 99202?99205 P128
150 days
This request type is to be used by military hospitals or clinics only
Trigger Point Injections Urgent Care *= generic request type
20552?20553 99202?99205
P41
90 days
5 days after and 15 days
P45
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 Continuing Outpatient Therapy (BH)
Included CPT?, NDC, HCPCS Codes
Request Type
90791?90792, 90832?90853, 99211?99215, 90785
P50
Electroconvulsive Therapy (BH)
90791?90792, 90870
P64
Initial Psychiatric Referral (BH)
90791?90792, 90832?90853, 99202-99205, 99211?99215, 90785
P49
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, J3490
P173
Transcranial Magnetic Stimulation (BH)
90791?90792, 90867?90869
BH = behavioral health, *= generic request type
P166
Approval Duration
90 days for codes 90791?90792
180 days for codes 90832? 90853, 99211?99215, 90785 90 days for codes 90791?90792
180 days for code 90870 90 days for codes 90791?90792, 99202-99205
180 days for codes 90832? 90853, 99211?99215, 90785 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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