Detailed Provider Information Required for Facility-Based Outpatient Physical and Occupational Therapy Claims

Thursday, September 8, 2022

Effective Dec. 17, 2020, TRICARE allows for podiatrists to prescribe physical or occupational therapy (PT or OT) within the scope of their license. Health Net Federal Services, LLC (HNFS) would like to remind facilities billing claims for PT/OT services referred by podiatrists to please include the ordering/referring provider and the attending/rendering provider information on all outpatient claims. This will allow us to accurately apply copayments and cost-shares. Without the specific provider information, claims for TRICARE Prime beneficiaries may process under the point-of-service option, and claims for TRICARE Select beneficiaries may reflect multiple copayments in error.

What to include on facility-based PT/OT claims:

Referring/ordering physician: Include the full name, National Provider Identifier (NPI), and NPI qualifier in fields 78-79 of the UB-04 (CMS-1450) form or in Loop 2310C/2310D/2310F of the HIPAA 837I (institutional) form.
Attending physician: Include the full name, NPI, and NPI qualifier in field 76 of the UB-04 (CMS-1450) form or in Loop 2310A of the HIPAA 837I (institutional) form.
Rendering physician: Include the full name, NPI and NPI qualifier in fields 78-79 of the UB-04 (CMS-1450) form or in Loop 2310C/2310D/2310F of the HIPAA 837I (institutional) form.

Podiatry PT/OT referral and coverage reminders

As a reminder, coverage for PT and OT is based on the beneficiary's medical needs. The number of visits authorized indicates the actual number of visits, not the individual units per code billed. Referral guidelines are based on plan type.

TRICARE Prime: While TRICARE Prime patients require a primary care manager (PCM) referral to see a podiatrist, they do not need a subsequent PCM referral for any PT or OT prescribed by network podiatrists. Only the podiatrist’s PT/OT order is needed for claims processing. (PT or OT prescribed by a non-network podiatrist will require a PCM referral.)
TRICARE Select: No referral is required for podiatric, PT or OT services for patients enrolled to TRICARE Select. However, the podiatrist’s order for PT or OT is needed for claims processing.

Find more information on our PT and OT benefits pages.