Specialty Referrals. Start of Code Range (Procedure Low Code) Request Request Profile Description. End of Code Range (Procedure High Code)

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1 What is a request profile? profiles are templates created for use with specialty referral, outpatient authorization, and outpatient behavioral health service request submissions. Each request profile has been developed by HNFS in accordance with the TRICARE manuals. When a request profile is selected, it will use the following procedure code(s) or procedure code range: Specialty Referrals P1 P3 Evaluate and Treat Specialty Referral Evaluate-Only Specialty Referral P4 Specialty Referral Extension P5 Second Opinion P63 Routine Eye Examination P58 Pre/Post Transplant TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 1

2 Outpatient Authorizations (Top 20 most common profiles listed first) P38 P36 P125 Physical Therapy Occupational Therapy Physical and Occupational Therapy TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 2

3 P39 Speech Therapy P126 Global OB ICD P105 Outpatient PH Surgical Procedure Generic. Enter CPT code(s). P106 Outpatient PH Medical Procedure Generic. Enter CPT code(s). P16P P16R P9 P155 P151 P26 P11 CPAP Purchase and Supplies CPAP Rental and Supplies Allergy Services CPAP Supplies Only ABA Tiered Provider Home Health PPS or Corp-Nursing Audiology E0601 A7027 E0601 A7027 E0601 E A T 0368T 0370T 0360T 0365T 0369T 0370T 0361T G0151 G0152 G0153 G0299 G0151 G0152 G0153 G TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 3

4 P34 Maternity Ultrasounds P43 Colonoscopy P40 Sleep Study P32 P33 Injection, Facet Joint (Cervical or Thoracic) Injection, Facet Joint (Lumbar or Sacral) P35 Observation Stay G0378 G0379 P10 Ambulance Services A0999 A0999 P12 Cardiac Rehabilitation P13 Pulmonary Rehabilitation G0237 G0238 P14 Chiropractic Care P15P P15R P17P P17R P18 Insulin Pump Purchase and Pump Supplies Insulin Pump Rental and Pump Supplies BiPap Purchase and Supplies BiPap Rental and Supplies Wheelchair Rental - Basic E0784 A4232 A4230 A4231 E0784 A4232 A4230 A4231 E0470 A7030 E0470 A7030 K0001 E0990 E0784 A4232 A4230 A4231 E0784 A4232 A4230 A4231 E0470 E0470 K0001 E0990 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 4

5 P19 P20 P21 Custom Wheelchair Purchase, Manual Custom Wheelchair Purchase, Power Wound Vacuum E0990 E0950 E0955 E0960 E0971 E0973 E0974 E0978 E2604 K0004 K0040 E0950 E0955 E0960 E0973 E0974 E0978 E2313 E2321 E2363 E2367 E2376 E2604 K0836 K0040 E2402 A6550 A7000 E0990 E0950 E0955 E0960 E0971 E0973 E0974 E0978 E2604 K0004 K0040 E0950 E0955 E0960 E0973 E0974 E0978 E2313 E2321 E2363 E2367 E2376 E2604 K0836 K0040 E2402 A6550 A7000 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 5

6 P22 Dental/Adjunctive Dental Svc Data Entry D9310 D9310 P23 Diabetic Education G0108 G0109 P24 Nutritional Counseling G0270 G0271 P28 Home Health Infusion Therapy A4221 A4221 P29 Injection, HPV P30 Injection, Epidural (Cervical or Thoracic) P31 Injection, Epidural (Lumbar or Sacral) P37 Osteopathic Manipulation P41 Trigger Point Injections P44 Emergency Room Visit P45 Urgent Care P46A Hospice P47 ECHO Respite Care P48 Hourly Skilled Nursing P54 CPM Machine - Knee E0935 E0935 P55 Synthetic Sheepskin Pad E0188 E0188 P56 Rolling Walker E0143 E0143 P57 3 in 1 Commode E0163 E0163 P59 Pulmonary Rehabilitation Pre/Post Transplant P60 Dialysis P61 LVAD L9900 L9900 P62 Smoking Cessation TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 6

7 P65 CPM Machine - Other E0936 E0936 P67 Synagis P101 Dental Anesthesia P107 Outpatient DME Rental and Med Supplies Generic Generic. Enter HCPC code(s). P108 Outpatient DME Purchase and Med Supplies Generic Generic. Enter HCPC code(s). P109 Outpatient Prosthetics and Orthotics Generic Generic. Enter HCPC code(s). P112 P113 P114 TENS Unit-Rental TENS Unit-Purchase Diabetic Eye Exam E0720 A4595 E0720 A4595 E0730 A4595 E0730 A P115 Outpatient Infusion Therapy or Medication Administration Generic. Enter CPT/HCPC code(s). P116 Air Ambulance Services A0430 A0431 P123 Sleep Study (Under 6 Years Old) P124 Hippotherapy S8940 S8940 P127 Adjunctive Dental Generic Generic. Enter CPT code(s). P129 BRCA1/BRCA P133 BMPR1A P135 CFTR P136 Cytogenomic Constitutional Microarry Analysis P148 P151 P153 SMN1/SMN2 ABA Tiered Provider ABA Initial Assessment T 0368T 0370T 0365T 0369T 0370T P154 ABA Outcome Measures P158 BreastFeeding Pump and Supplies E0602 A4281 A9999 E0603 A4286 A9999 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 7

8 (Procedure High ) P159 BreastFeeding Counseling P160 P161 Heavy Duty Hospital Grade Breast Pump And Supplies Personal Incontinence Supplies E0604 A4281 A9999 A4520 T4521 T4539 T4543 P162 Non-USFDA LDTs Demo Generic Generic. Enter CPT code(s). E0604 A4286 A9999 A4520 T4536 T4539 T4544 P163 Acupuncture P165 Custodial Care Home TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 8

9 Outpatient Behavioral Health P49 P50 BH Initial Eight BH Continuing Outpatient Therapy P51 BH Medication Management P52 P53 P64 BH Psychological Testing BH Neuro Psychological Testing BH Electroconvulsive Therapy P71 BH PHP Psych Full Day P72 BH PHP Substance Abuse Full Day P73 BH PHP Psych Half Day P74 BH PHP Substance Abuse Half Day P75 BH Observation Stay G0379 G0379 P85 BH Outpatient Services Generic. Enter CPT code(s). P152 Opioid Replacement Therapy (ORT) P156 BH IOP Psych S9480 S9480 P157 BH IOP Substance Abuse H0015 H0015 P166 BH Transcranial Magnetic Stimulation P167 BH Medication Assistant Treatment Generic. Enter CPT code(s). TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 9

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