The TRICARE OPPS pays claims filed for hospital outpatient services, including hospital-based PHPs (psychiatric and SUDRF) subject to TRICARE’s prior authorization requirements. The outpatient code editor logic requires that hospital-based PHPs provide a minimum of three units of service per day in order to receive PHP payment.
TRICARE has adopted Medicare’s PHP reimbursement methodology for hospital-based PHPs. There are two separate APC payment rates under this reimbursement methodology:
In addition, TRICARE allows physicians, clinical psychologists, clinical nurse specialists, NPs and PAs to bill separately for their professional services delivered in a PHP. The only professional services included in the PHP per diem payments are those furnished by clinical social workers, occupational therapists and alcohol and addiction counselors.
The claim must include a behavioral health diagnosis and an authorization on file for each day of service. Since there is no HCPCS code that specifies a partial hospitalization-related service, partial hospitalizations are identified by a particular bill type and condition code.
For more information about how OPPS affects TRICARE PHPs and for a complete listing of applicable revenue and HCPCS codes, refer to the TRICARE Reimbursement Manual, Chapter 13, Section 2