Partial Hospitalization Program Claims Tips

TRICARE covers limited behavioral health services rendered in a TRICARE-authorized partial hospitalization program (PHP). The following tips should be used to ensure accurate and timely reimbursement for services provided.

Hospital-based PHPs
When a hospital is a TRICARE-authorized (certified) provider (Joint Commission Accreditation required for Network), the hospital’s PHP shall also be considered a TRICARE-authorized provider.

Freestanding PHPs
Must be certified and enter into a participation agreement with TRICARE and obtain the required
preauthorization prior to admitting patients. Applications for freestanding PHP certification may be obtained from KePRO.

Prior authorization is required for PHP services for all TRICARE beneficiaries.

Providers should submit a new request for services before rendering services that differ or extend beyond the original Health Net Federal Services, LLC (HNFS) approval. For example:

• A full day was approved, but only a half day was billed – the claim will be processed as submitted
• A half day was approved, but a full day was billed – the claim will undergo review for extra services and a penalty will be applied

Include the Correct Primary Diagnosis

If services provided are for psychiatric services, the primary diagnosis must be psychiatric. Likewise, if services provided are for chemical dependency, the primary diagnosis must be chemical dependency.

Freestanding PHPs and Outpatient Prospective Payment System (OPPS) – Exempt Hospital-Based PHPs

These facilities are reimbursed under the PHP per diem payment methodology outlined in the TRICARE Reimbursement Manual, chapter 7, section 2. 

These facilities must be billed on a UB-04 with one of the following:

1. Revenue code 912 for: 
   • Psychiatric Partial Hospitalization – all-inclusive per diem payment of three to five hours (half day); or
   • Chemical Dependency Partial Hospitalization – all-inclusive per diem payment of three to five hours (half day)
2. Revenue code 913 for: 
   • Psychiatric Partial Hospitalization – all-inclusive per diem payment of six or more hours (full day); or
   • Chemical Dependency Partial Hospitalization – all inclusive per diem payment of six or more hours (full day)

Note: Revenue codes must be billed separately for each date of service.

Professional provider services furnished by clinical social workers, occupational therapists and alcohol and addiction counselors are included in the PHP per diem payment whether the providers are employed or contracted by the PHP.

Hospital-Based OPPS PHPs

For hospital-based PHPs subject to OPPS, there are three Ambulatory Payment Classification (APC) payment rates:

• Days with three services or units of service – APC 05861
• Days with four or more services or units of service – APC 05862
• Intensive outpatient program (IOP) services – APC T0175

These hospitals must bill according to OPPS guidelines on a UB-04 with the following codes:

• Bill type 013X
• Condition code 41
• Must bill using the HCPCS codes for the actual services rendered in addition to the date for each service rendered

Additionally, TRICARE states physicians, clinical psychologists, clinical nurse specialists, nurse practitioners and physician assistants must bill separately for their professional services delivered in an OPPS hospital-based PHP.

Effective July 1, 2016, under the new payment policy, the following PHP billing requirements apply for TRICARE claims:

• Interim PHP claims (bill type 763 or 133 with condition code 41) must have from and through dates that span five or more days.
• Regular PHP claims must be billed weekly (calendar week is defined from Sunday through Saturday).