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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyDHA TRICARE Institutional Care Coverage | OpenPaye…
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    CurrentDHAPolicy 3.0

    TRICARE Institutional Care Coverage

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    This DHA/TRICARE policy manual organizes coverage, payment, authorization, coding, and clinical policy requirements across institutional and other healthcare services; the available portion is limited to the table of contents and does not include substantive institutional-care criteria.

    Policy Summary
    PayerDHA
    PolicyTRICARE Institutional Care Coverage
    Policy CodePolicy 3.0
    Change TypeNo material change
    Effective DateSep 1, 2005
    Next Review DateN/A
    Key ActionEnsure all five conditions are met before providing for-profit institutional care.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Eligible institution types
    5For-profit exception conditions
    2Explicit exclusions
    99199CPT code listed
    TRICARELine of business

    Institutional Care Coverage Criteria

    Standard institutional care

    Institutional care may be cost-shared when all applicable ECHO requirements are met.

    Standard institutional care eligibility

    • The severity of the qualifying condition requires protective custody or training in a residential environment.
    • The care is provided in a private nonprofit, public, or state institution or facility.
    • All applicable Extended Care Health Option (ECHO) requirements are met.

    For-profit institutional care

    For-profit institutional care may be allowed only when all of the following conditions are met.

    For-profit institutional care exception

    Policy Summary
    PayerDHA
    PolicyTRICARE Institutional Care Coverage
    Policy CodePolicy 3.0
    Change TypeNo material change
    Effective DateSep 1, 2005
    Next Review DateN/A
    Key ActionEnsure all five conditions are met before providing for-profit institutional care.
    SourceLink
    On This Page
    Institutional Care Coverage CriteriaApplicable CodingProvider and Billing ConsiderationsInstitutional Care Program Context

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    • The care for the specific ECHO beneficiary is contracted for by a public facility as part of a publicly funded long-term inpatient care program.
    • The ECHO beneficiary is eligible for the publicly funded program that contracted for the care.
    • The care is authorized by the public facility as part of the publicly funded program.
    • The care would cause a cost-share liability in the absence of TRICARE eligibility.
    • The ECHO beneficiary's cost-share liability does not exceed the provider's maximum charge to the public facility for the contracted level of care.

    Excluded institutional care: Regardless of the beneficiary’s condition, care provided in any type of institution primarily for custodial, domiciliary, hospice, or respite purposes is excluded from ECHO.

    Institutional care available under the TRICARE Basic Program is not eligible for cost-sharing under ECHO.

    Applicable Coding

    CPT CodesCPT
    99199CPT CODE

    Provider and Billing Considerations

    Denial Risk

    Excluded Custodial or Supportive Care

    Custodial, domiciliary, hospice, and respite care is excluded from ECHO cost-sharing, regardless of the beneficiary's condition. Institutional care provided primarily for these purposes should be denied under the ECHO.

    Denial Risk

    TRICARE Basic Program Overlap

    Institutional care available under the TRICARE Basic Program is not eligible for cost-sharing under the ECHO. Confirm that the institutional care is not being covered under the Basic Program before billing ECHO.

    Denial Risk

    For-Profit Institutional Care Exception

    Institutional care must generally be provided by a private nonprofit, public, or state institution or facility. Care provided by a for-profit entity is eligible only when all specified exception criteria are satisfied.

    • The care is contracted for by a public facility as part of a publicly funded long-term inpatient care program.
    • The beneficiary is eligible for the publicly funded program that contracted for the care.
    • The public facility authorized the care as part of the publicly funded program.
    • The care would create a cost-share liability in the absence of TRICARE eligibility.
    • The beneficiary's ECHO cost-share liability does not exceed the provider's maximum charge to the public facility for the contracted level of care.
    • If any condition is unmet, the for-profit institutional care is ineligible for ECHO cost-sharing.

    Institutional Care Program Context

    ECHO institutional care applies to residential settings when the severity of a beneficiary’s qualifying condition requires protective custody or training in a residential environment. Coverage remains subject to applicable ECHO requirements, including exclusions for care primarily intended for custodial, domiciliary, hospice, or respite purposes and restrictions on care available under the TRICARE Basic Program.