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 99201 99205 99241 99245 99201 99205 99241 99245 P4 Specialty Referral Extension 99201 99205 P5 Second Opinion 99241 99245 P63 Routine Eye Examination 92002 92015 P58 Pre/Post Transplant 99241 99245 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 1
Outpatient Authorizations (Top 20 most common profiles listed first) P38 P36 P125 Physical Therapy Occupational Therapy Physical and Occupational Therapy 97161 97163 97164 97164 97010 97024 97028 97036 97110 97124 97140 97150 95831 95834 95851 95852 97530 97530 97165 97167 97168 97168 97010 97024 97028 97036 97110 97124 97140 97150 95831 95834 95851 95852 97530 97530 97165 97167 97168 97168 97010 97024 97028 97036 97110 97124 97140 97150 97161 97163 97164 97164 97010 97024 97028 97036 97110 97124 97140 97150 95831 95834 95851 95852 97530 97530 97530 97530 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 2
P39 Speech Therapy 92521 92524 92507 92507 P126 Global OB ICD-10 59400 59622 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 E0601 95004 95004 95017 95117 A7027 0364T 0368T 0370T 0360T 0365T 0369T 0370T 0361T 0023 0023 G0151 G0152 G0153 G0299 G0151 G0152 G0153 G0300 92550 92550 92552 92557 92563 92588 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 3
P34 Maternity Ultrasounds 76801 76817 P43 Colonoscopy 45300 45392 P40 Sleep Study 95810 95811 P32 P33 Injection, Facet Joint (Cervical or Thoracic) Injection, Facet Joint (Lumbar or Sacral) 64490 64490 64491 64491 64492 64492 64493 64493 64494 64494 64495 64495 P35 Observation Stay G0378 G0379 P10 Ambulance Services A0999 A0999 P12 Cardiac Rehabilitation 93797 93798 P13 Pulmonary Rehabilitation G0237 G0238 P14 Chiropractic Care 98940 98943 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
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
P22 Dental/Adjunctive Dental Svc Data Entry D9310 D9310 P23 Diabetic Education G0108 G0109 P24 Nutritional Counseling 97802 97804 G0270 G0271 P28 Home Health Infusion Therapy 99601 99601 99602 99602 A4221 A4221 P29 Injection, HPV 90649 90649 P30 Injection, Epidural (Cervical or Thoracic) 62320 62321 77003 77003 P31 Injection, Epidural (Lumbar or Sacral) 62322 62323 77003 77003 P37 Osteopathic Manipulation 98925 98929 P41 Trigger Point Injections 20552 20553 P44 Emergency Room Visit 99281 99285 P45 Urgent Care 99201 99205 P46A Hospice 0651 0657 0551 0551 0561 0561 0571 0571 P47 ECHO Respite Care 99600 99600 P48 Hourly Skilled Nursing 99347 99347 99347 99347 99347 99347 99347 99347 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 97161 97163 97110 97110 P60 Dialysis 90935 90935 P61 LVAD L9900 L9900 P62 Smoking Cessation 96152 96152 96153 96153 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 6
P65 CPM Machine - Other E0936 E0936 P67 Synagis 90378 90378 P101 Dental Anesthesia 41899 41899 00170 00170 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 A4595 92082 92082 92250 92250 99203 99204 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) 95782 95783 P124 Hippotherapy S8940 S8940 P127 Adjunctive Dental Generic Generic. Enter CPT code(s). P129 BRCA1/BRCA2 81211 81217 P133 BMPR1A 81479 81479 P135 CFTR 81220 81224 P136 Cytogenomic Constitutional Microarry Analysis 81228 81229 81406 81406 P148 P151 P153 SMN1/SMN2 ABA Tiered Provider ABA Initial Assessment 81400 81400 81401 81401 81403 81403 81405 81405 0364T 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
(Procedure High ) P159 BreastFeeding Counseling 99401 99404 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 97810 97810 P165 Custodial Care Home 99600 99600 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 3/9/2018. Page 8
Outpatient Behavioral Health P49 P50 BH Initial Eight BH Continuing Outpatient Therapy 90832 90853 99201 99205 90785 90785 90832 90853 90785 90785 P51 BH Medication Management 99201 99215 P52 P53 P64 BH Psychological Testing BH Neuro Psychological Testing BH Electroconvulsive Therapy 96101 96103 96118 96120 90870 90870 P71 BH PHP Psych Full Day 0913 0913 P72 BH PHP Substance Abuse Full Day 0913 0913 P73 BH PHP Psych Half Day 0912 0912 P74 BH PHP Substance Abuse Half Day 0912 0912 P75 BH Observation Stay G0379 G0379 P85 BH Outpatient Services Generic. Enter CPT code(s). P152 Opioid Replacement Therapy (ORT) 0912 0913 P156 BH IOP Psych S9480 S9480 P157 BH IOP Substance Abuse H0015 H0015 P166 BH Transcranial Magnetic Stimulation 90867 90869 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