PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE ...€¦ · when prescribed action has been taken, file this transmittal with basic document. hpod change 172 6010.58-m march 11,

HPOD CHANGE 1726010.58-MMARCH 11, 2019

PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FORTRICARE REIMBURSEMENT MANUAL (TRM), FEBRUARY 2008

The Defense Health Agency has authorized the following addition(s)/revision(s).

CHANGE TITLE: CONSOLIDATED CHANGE 18-006

CONREQ: 19813

SUMMARY OF CHANGE(S): See page 3.

EFFECTIVE DATE: See page 3.

IMPLEMENTATION DATE: April 12, 2019.

This change is made in conjunction with Feb 2008 TPM, Change No. 219, and Feb 2008 TSM, Change No. 113.

Jose L. LozoyaChief, Manuals Change SectionDefense Health Agency (DHA)

WHEN PRESCRIBED ACTION HAS BEEN TAKEN, FILE THIS TRANSMITTAL WITH BASIC DOCUMENT.

CHANGE 1726010.58-MMARCH 11, 2019

REMOVE SECTION(S) INSERT SECTION(S)

CHAPTER 1

★ ★ ★ ★ ★ ★ Addendum D.

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CHANGE 1726010.58-M

MARCH 11, 2019

SUMMARY OF CHANGES

CHAPTER 1

1. Section 11. Adds a reference to Breastfeeding Supplies. EFFECTIVE DATE: 07/05/2018.

2. Addendum D. Adds a new section regarding Breastfeeding Supplies. EFFECTIVE DATE: 07/05/2018.

CHAPTER 4

3. Section 4. Clarifies language regarding Medicare Part B services provided in a Department of Veterans Affairs Facility. EFFECTIVE DATE: 04/26/2019.

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008

Chapter 1

General

Section/Addendum Subject/Addendum Title

1 Network Provider Reimbursement

2 Accommodation Of Discounts Under Provider Reimbursement Methods

3 Claims Auditing Software

4 Reimbursement In Teaching Setting

5 National Health Service Corps Physicians Of The Public Health Service

6 Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)

7 Reimbursement Of Covered Services Provided By Individual Health Care Providers And Other Non-Institutional Health Care Providers

8 Economic Interest In Connection With Mental Health Admissions

9 Anesthesia

10 Postoperative Pain Management - Epidural Analgesia

11 Claims For Durable Equipment (DE) And Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)

12 Oxygen And Related Supplies

13 Laboratory Services

14 Ambulance ServicesFigure 1.14-1 Ground Ambulance Scenarios In Which The Beneficiary DiesFigure 1.14-2 Air Ambulance Scenarios in Which The Beneficiary DiesFigure 1.14-3 Air Ambulance Scenarios in Which The flight is aborted

15 Legend Drugs And Insulin

16 Surgery

17 Assistant Surgeons

18 Professional Services: Obstetrical Care

19 Charges For Provider Administrative Expenses

20 State Agency Billing

21 Hospital Reimbursement - Billed Charges Set Rates

22 Hospital Reimbursement - Other Than Billed Charges

23 Hospital Reimbursement - Payment When Only Skilled Nursing Facility (SNF) Level Of Care Is Required

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008Chapter 1, General

Section/Addendum Subject/Addendum Title

24 Hospital Reimbursement - Outpatient Services

25 Preferred Provider Organization (PPO) Reimbursement

26 Supplemental Insurance

27 Legal Obligation To Pay

28 Reduction Of Payment For Noncompliance With Utilization Review Requirements

29 Reimbursement Of Emergency Inpatient Admissions To Unauthorized Facilities

30 Reimbursement Of Travel Expenses For Specialty Care

31 Newborn Charges

32 Hospital-Based Birthing Room

33 Bonus Payments In Health Professional Shortage Areas (HPSAs)

34 Hospital Inpatient Reimbursement In Locations Outside The 50 United States And The District Of ColumbiaFigure 1.34-1 Country Specific Index FactorsFigure 1.34-2 Institutional Inpatient Diagnostic Groupings For Specified

Locations Outside The 50 United States And The District Of Columbia - National Inpatient Per Diem Amounts

Figure 1.34-3 Unique Admissions - National Inpatient Per Diem Amounts

35 Professional Provider Reimbursement In Specified Locations Outside The 50 United States And The District Of ColumbiaFigure 1.35-1 Country Specific Index Factors

36 Forensic Examinations Following Sexual Assault or Domestic Violence

37 Medical Errors

38 Reimbursement of State Vaccine Programs (SVPs)

A Sample State Agency Billing Agreement

B FiguresFigure 1.B-1 Suggested Wording To The Beneficiary Concerning Rental vs.

Purchase Of DME

C Minimum Requirements For Reimbursement Of Per Capita Based (Or Alternative) State Vaccine Programs (SVPs)

D Maximum Allowable Charge For Breastfeeding SuppliesFigure 1.D-1 National Prevailing Charge For Breastfeeding Supplies With A

Specific HCPCS Code For Service Dates On Or After July 5, 2018Figure 1.D-2 TOP National Prevailing Charge For Breastfeeding Supplies With

A Specific HCPCS Code For Service Dates On Or After July 5, 2018

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008Chapter 1,

Figure 1.D-3 National Prevailing Charge For Breastfeeding Supplies Without A Specific HCPCS Code For Service Dates On Or After July 5, 2018

Figure 1.D-4 TOP National Prevailing Charge For Breastfeeding Supplies Without A Specific HCPCS Code For Service Dates On Or After July 5, 2018

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008Chapter 1, Section 11

Claims For Durable Equipment (DE) And Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)

equipment during a base period, updated to account for inflation. For each of the remaining months, the monthly rental is limited to 7.5% of the average allowed purchase price.

4.10.2 After paying the rental DMEPOS fee schedule amount for 15 months, no further payment may be made except for reasonable and necessary maintenance and servicing. Reasonable and necessary charges for maintenance and servicing are those made for parts and labor not otherwise covered under a manufacturer’s or supplier’s warranty.

4.10.3 Modifiers used in this category are as follows:

4.10.4 Claims Adjudication Determinations.

4.10.4.1 Adjudication of DE/DME claims involves a two-step sequential process involving the following determinations by the contractor:

Step 1: Whether the equipment meets the definition of DE/DME, is medically necessary, and is otherwise covered; and

Step 2: Whether the equipment should be rented or obtained through purchase (including lease/purchase). To arrive at a determination, the following information is required:

• A statement of the patient’s prognosis and the estimated length of medical necessity for the equipment.

• The reasonable monthly rental charge.

• The reasonable purchase cost of the equipment.

• The contractor must determine whether, given the estimated period of medical necessity, it would be more economical and appropriate for the equipment to be rented or purchased.

RR Rental

KH First month rental

KI Second and third month rental

KJ Fourth to fifteenth months

BR Beneficiary elected to rent

BP Beneficiary elected to purchase

BU Beneficiary has not informed supplier of decision after 30 days

MS Maintenance and Servicing

NU New equipment

UE Used equipment

NR New when rented

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4.10.4.2 If the beneficiary opts to rent/purchase, the contractor must establish a mechanism for making regular monthly payments without requiring the claimant to submit a claim each month. (It is not required or expected that the contractor will automate the automatic payment; the volume of this type claim will be quite low.) In cases of “indefinite needs,” medical necessity must be evaluated after the first three months and every six months thereafter. Special care should be taken to avoid payment after termination of TRICARE eligibility or in excess of the total allowable benefit. In making monthly payments, the contractor will report on the TRICARE Encounter Data (TED) only that portion of the billed charge which is applicable to that monthly payment. (See the TRICARE Systems Manual (TSM), Chapter 2.) For example, a wheelchair is being purchased for which the total charge is $770. The contractor determines that payments will be made over a 10-month period. The allowed charge is $600. The contractor will show the monthly billed charge as $77 and $60 as the allowed.

4.10.5 Notice To Beneficiary. When the contractor makes a determination to rent or purchase, the beneficiary shall be notified of that determination. The beneficiary is not required to follow the contractor’s determination. He or she may purchase the equipment even though the contractor has determined that rental is more cost effective. However, payment for the equipment will be based on the contractor’s determination. Because of this, the notice should be carefully worded to avoid giving any impression that compliance is mandatory, but should caution the beneficiary concerning the expenses in excess of the allowed amount. Suggested wording is included in Addendum B.

4.11 Automatic Mailing/Delivery of DMEPOS.

Contractors shall ensure that all DMEPOS services are medically necessary and appropriate, to include refills of repetitive services and/or supplies, and any automatically dispensed quantities of supplies on a predetermined regular basis.

4.12 Oxygen and oxygen equipment. Oxygen and oxygen equipment is to be reimbursed in accordance with Section 12.

4.13 Parenteral/enteral nutrition therapy. Parenteral/enteral pumps can be either rented or purchased.

4.14 Splints and Casts. The reimbursement rates for these items of DMEPOS shall be based on Medicare’s pricing.

4.15 Reimbursement Rates.

4.15.1 The DMEPOS pricing information is available at https://www.health.mil/rates and the contractors are required to replace the existing pricing with the updated pricing information within 10 calendar days of publication on the Internet.

4.15.2 The pricing for splints and casts is included in the DMEPOS pricing available at https://www.health.mil/rates.

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4.15.3 Refer to Chapter 1, Addendum D for payment of breastfeeding supplies that are not listed in the DMEPOS fee schedule.

4.15.4 See the TRICARE Operations Manual (TOM), Chapter 1, Section 4 regarding updating and maintaining TRICARE reimbursement systems.

4.16 Inclusion or exclusion of a DMEPOS fee schedule amount for an item or service does not imply any TRICARE coverage.

4.17 Extensive maintenance which, based on manufacturer recommendations, must be performed by authorized technicians is covered as medically necessary. This may include breaking down sealed components and performing tests that require specialized testing equipment not available to the beneficiary. Maintenance may be covered for patient owned-DME when such maintenance must be performed by an authorized technician.

4.18 Replacement and Repair of DMEPOS. The following modifiers are to be used to identify repair and replacement of an item.

4.18.1 RA - Replacement of an item. The RA modifier on claims denotes instances where an item is furnished as a replacement for the same item which has been lost, stolen, or irreparable damaged.

4.18.2 RB - Replacement of a part of DME furnished as part of a repair. The RB modifier indicates replacement parts of an item furnished as part of the service of repairing the item.

5.0 EXCLUSIONS AND LIMITATIONS

5.1 A cost that is non-advantageous to the government shall not be allowed even when the equipment cannot be rented or purchased within a “reasonable distance” of the beneficiary’s current address. The charge for delivery and pick up is an allowable part of the cost of an item; consequently, distance does not limit access to equipment.

5.2 Line-item interest and carrying charges for equipment purchase shall not be allowed. A lump-sum payment for purchase of an item of equipment is the limit of the government cost-share liability. Interest and carrying charges result from an arrangement between the beneficiary and the equipment vendor for prorated payments of the beneficiary’s cost-share liability over time.

5.3 Routine periodic servicing such as testing, cleaning, regulating, and checking that is generally expected to be done by the owner. Normally, the purchasers are given operating manuals that describe the type of service an owner may perform. Payment is not made for repair, maintenance, and replacement of equipment that requires frequent substantial servicing, oxygen equipment, and capped rental items that the patient has not elected to purchase.

6.0 EFFECTIVE DATES

6.1 September 1, 2005, for the DMEPOS system.

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6.2 April 1, 2011, for reimbursement of splints and casts.

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008General

Chapter 1 Addendum D

Maximum Allowable Charge For Breastfeeding Supplies

1.0 APPLICABILITY

This policy is mandatory for reimbursement of services provided by either network or non-network providers. However, alternative network reimbursement methodologies are permitted when approved by the Defense Health Agency (DHA) and specifically included in the network provider agreement.

2.0 DESCRIPTION

This addendum provides the payment amounts and procedures for reimbursing breastfeeding supplies for which Medicare does not have an established fee schedule rate, in accordance with the procedures established in 32 CFR 199.14(j)(1). For network providers, the contractor may negotiate rates that would be less than the rates established under this addendum, in accordance with contractual agreements.

3.0 POLICY

For coverage policy and allowable limits on breast pumps, breast pump supplies, and breastfeeding counseling, see the TRICARE Policy Manual (TPM), Chapter 8, Section 2.6. Effective for service dates on or after July 5, 2018, the maximum allowable charge is limited to the lower of the billed charge, negotiated rate, or the national prevailing charge, as established by this Addendum.

4.0 REIMBURSEMENT

4.1 Effective for service dates on or after July 5, 2018, for breastfeeding supplies that have a specific Health Common Procedure Coding System (HCPCS) code:

4.1.1 The national prevailing charge was calculated by using the 80th percentile of all the billed charges during the 12 month period ending June 30, 2017. In the process of calculating the national prevailing charge, outliers were removed that were above an upper limit threshold of what the Government established to be “customary and reasonable”, in accordance with 32 CFR 199.9 definitions of abusive and excessive charges.

4.1.2 The national prevailing charge for these items are in Figure 1.D-1 and TRICARE Overseas Program (TOP) Figure 1.D-2. To account for local currency, exchange rate fluctuation, limits on availability, shipping, and other considerations, for claims that are processed under the TOP the national prevailing charge for the electric breast pump (HCPCS E0603) is $500 and twice the rate established for the other supplies. The TOP rates shall only apply to items that are purchased overseas (all locations outside of the 50 United States and the District of Columbia) and received from an overseas supplier. Suppliers located in the United States who ship overseas shall be limited to the rates in Figure 1.D-1.

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Note: Hospital grade breast pumps may be provided on a rental or purchase basis. As of 2018, market research has shown the average rental rate for a hospital pump is $70 (and $140 under the TOP). Therefore, any charges that are significantly higher from these amounts for the rental of HCPCS Code E0604 shall be evaluated for excessive and abusive charges. Coverage shall be based on the price most advantageous to the government in accordance with 32 CFR 199.4(d)(3)(ii)(D).

4.1.3 Updates to the national prevailing charge will occur annually, and they will be adjusted by the same update factor used to update the annual CHAMPUS Maximum Allowable Charge (CMAC) file. These rates shall not be wage adjusted for localities.

4.1.4 Effective with the 2019 CMAC update and subsequent updates, the updated rates for these items will be in the annual CMAC file that is supplied to the contractors by the DHA. The annual update usually takes place February 1. However, circumstances may cause the updates to be delayed. Contractors will be notified when the annual update is delayed.

FIGURE 1.D-1 NATIONAL PREVAILING CHARGE FOR BREASTFEEDING SUPPLIES WITH A SPECIFIC HCPCS CODE FOR SERVICE DATES ON OR AFTER JULY 5, 2018

HCPCS CODE DESCRIPTION RATE PER UNIT

A4281 Tubing for breast pump $10.00

A4282 Adapter for breast pump $19.09

A4283 Cap for breast pump bottle $2.00

A4284 Breast shield and splash protector $9.99

A4285 Polycarbonate bottle $3.00

A4286 Locking ring $1.50

E0602 Manual breast pump purchase Refer to the CMS DMEPOS fee schedule

E0603 Electric breast pump purchase $312.50

E0604 Hospital grade breast pump purchase $1,500.00

FIGURE 1.D-2 TOP NATIONAL PREVAILING CHARGE FOR BREASTFEEDING SUPPLIES WITH A SPECIFIC HCPCS CODE FOR SERVICE DATES ON OR AFTER JULY 5, 2018


A4281 Tubing for breast pump $20.00

A4282 Adapter for breast pump $38.18

A4283 Cap for breast pump bottle $4.00

A4284 Breast shield and splash protector $19.98

A4285 Polycarbonate bottle $6.00

A4286 Locking ring $3.00

E0602 Manual breast pump purchase Contact International SOS

E0603 Electric breast pump purchase $500.00

E0604 Hospital grade breast pump purchase $3,000.00

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4.1.5 Future pricing will not be published in this manual, since the rates will be updated and made available at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Durable-Medical-Equipment-Prosthetics-Orthotics-and-Supplies.

4.2 Effective for service dates on or after July 5, 2018, for breastfeeding supplies that do not have a specific HCPCS code:

4.2.1 The national prevailing charge was set at the upper limit of what the Government has established as a “customary and reasonable” charge, in accordance with the definitions of abusive and excessive billing practices found in 32 CFR 199.9.

4.2.2 The national prevailing charge for these items are in Figure 1.D-3 and TOP Figure 1.D-4. The TOP rates shall only apply to items that are purchased overseas (all locations outside of the 50 United States and the District of Columbia) and received from an overseas supplier. Suppliers located in the United States who ship overseas shall be limited to rates in Figure 1.D-3.

4.2.3 Updates to the national prevailing charge will occur annually, and they will be adjusted by the same update factor used to update the annual CMAC file. These rates shall not be wage adjusted for localities.

4.2.4 Updated rates for these items will not be in the annual CMAC file that is supplied to the contractors.

4.2.5 Future pricing will not be published in this manual, since the rates will be updated and made available at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Durable-Medical-Equipment-Prosthetics-Orthotics-and-Supplies.

- END -

FIGURE 1.D-3 NATIONAL PREVAILING CHARGE FOR BREASTFEEDING SUPPLIES WITHOUT A SPECIFIC HCPCS CODE FOR SERVICE DATES ON OR AFTER JULY 5, 2018


N/A Valves $15.00

N/A Breast milk storage bags $0.20

N/A Nipple shields $7.50

N/A Supplemental Nursing Systems (SNS) $75.00

FIGURE 1.D-4 TOP NATIONAL PREVAILING CHARGE FOR BREASTFEEDING SUPPLIES WITHOUT A SPECIFIC HCPCS CODE FOR SERVICE DATES ON OR AFTER JULY 5, 2018


N/A Valves $30.00

N/A Breast milk storage bags $0.40

N/A Nipple shields $15.00

N/A Supplemental Nursing Systems (SNS) $150.00

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Specific Double Coverage Actions

TRICARE processes as secondary payer, TRICARE first payer review and reporting rules apply. The TRICARE payment will be the amount that TRICARE would have paid (TRICARE cost-shares and deductibles do not apply) had the Medicare program processed the claim (normally 20% of the allowable charge). If there is not an available Medicare allowed amount, the TRICARE allowed amount shall be calculated and 20% of that amount will be reimbursed (TRICARE cost-shares and deductibles do not apply). Evidence of processing by Medicare for non-Medicare providers is not required; rather a statement from the provider verifying their Medicare status is sufficient for processing. Opt out providers will be identified based on the Medicare Part B carriers web sites. In cases where the beneficiary’s access to medical care is limited (i.e., under served areas), the TRICARE contractor may waive the 20% of the allowable charge payment amount and pay 100% of the allowable amount assessing all applicable deductibles and cost-shares. In most cases, under served areas will be identified by zip codes for Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs) on the Centers for Medicare and Medicaid Services (CMS) web site at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HPSAfctsht.pdf and will automatically pay 100% of the allowable amount assessing all applicable deductibles and cost-shares. In cases where the zip code for an underserved area is not identified on the CMS web site, or in areas where there are no or limited Medicare participating providers, a written waiver request with justification identifying the county where the service was received will be required by the contractor to pay 100% of the allowable amount assessing all applicable deductibles and cost-shares. TRICARE contractors will identify HPSA or PSA zip codes or the county for underserved areas on the above CMS web site and identify opt out providers based on the Medicare Part B carriers web sites.

1.3.1.6 When Medicare does not make a payment based on their Competitive Bidding Program (CBP) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), the TRICARE contractor shall process the claim as second payer for otherwise TRICARE covered items of DMEPOS. In these cases, when TRICARE processes as secondary payer, TRICARE first payer review and reporting rules apply. The TRICARE payment shall be the amount TRICARE would have paid (cost-shares and deductibles do not apply) had Medicare processed and paid the claim (normally 20% of the allowable charge). If there is not an available Medicare allowed amount, the TRICARE allowed amount shall be calculated and 20% of that amount will be reimbursed (cost-shares and deductibles do not apply). Public use files containing the competitive bid single payment amounts per Healthcare Common Procedure Coding System (HCPCS) code are posted on the CMS’ competitive bidding contractor’s web site: http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home. TRICARE contractors shall identify the competitive bid single payment amount using the above CMS web site to identify what Medicare would have allowed had the beneficiary followed Medicare’s rules. Implementation of Medicare’s DMEPOS CBP pricing is effective January 1, 2011.

1.3.1.7 When Medicare does not make a payment because Medicare rules were not followed or because the beneficiary failed to meet some other requirement of coverage (e.g., denied for no referral, no or untimely authorization, invalid place of service, etc.). TRICARE will process the claim as second payer as long as the services meet TRICARE coverage rules. This exception does not include Medicare medical necessity denials. In these cases, when TRICARE processes as secondary payer, TRICARE first payer review and reporting rules apply. The TRICARE payment will be the amount that TRICARE would have paid (TRICARE cost-shares and deductibles do not apply) had the Medicare program processed the claim (normally 20% of the allowed charge). If there is not an available Medicare allowed amount, the TRICARE allowed amount shall be calculated and 20% of that amount will be reimbursed (TRICARE cost-shares and deductible do not apply).

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HPSAfctsht.pdf



http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home

http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home



Note: TRICARE will not cost-share items designated by Medicare as “inpatient only” for Medicare beneficiaries. These services shall be denied, and TRICARE will make no payment. A list of these services can be found in the addenda to Medicare’s annual Outpatient Prospective Payment System Final Rule, available at https://www.cms.gov/Center/Provider-Type/Hospital-Center.html.

1.3.1.8 Effective October 28, 2009, TRICARE beneficiaries who are entitled to premium-free Medicare Part A because of disability, where Social Security Disability Insurance (SSDI) is awarded on appeal remain eligible for coverage under the TRICARE program (see the TOM, Chapter 20, Section 1, paragraph 2.6). Eligible beneficiaries are required to keep Medicare Part B in order to maintain their TRICARE coverage for future months, but are considered to have coverage under the TRICARE program for the retroactive months of their entitlement to Medicare Part A. For previously processed claims the contractor that processed the claim shall not initiate recoupment due to eligibility or jurisdiction and existing actions should be terminated. Medicare becomes primary payer effective as of the original Medicare Part B effective date.

1.3.2 Services That Are A Benefit Under Medicare But Not Under TRICARE

TRICARE will make no payment for services and supplies that are not a benefit under TRICARE, regardless of any action Medicare may take on the claim.

1.3.3 Services That Are A Benefit Under TRICARE But Not Under Medicare

If the service or supply is a benefit under TRICARE but never covered under Medicare, TRICARE will process the claim as the primary payer assessing any applicable deductibles and cost-shares. If the contractor has the documentation (e.g., Medicare transmittal or regulation) to support that Medicare would never cover the service or supply on the claim, the contractor can process the claim without evidence of processing by Medicare for that service or supply. These claims shall be handled in accordance with 32 CFR 199.10(a)(1)(ii). This includes services billed with the GY modifier (Medicare statutory exclusion or does not meet the definition of any Medicare benefit) and services provided to a beneficiary participating in Cancer Clinical Trials that are not a Medicare benefit.

1.3.4 Services That Are Provided In A DVA Facility

1.3.4.1 If services or supplies are provided in a TRICARE authorized DVA hospital pursuant to the TPM, Chapter 11, Section 2.1, Medicare will make no payment. In such cases TRICARE will process the claim as a second payer. In these cases, when TRICARE processes as secondary payer, TRICARE first payer review and reporting rules apply. The TRICARE payment will be the amount that TRICARE would have paid (TRICARE cost-shares and deductibles do not apply) had the Medicare program processed the claim (normally 20% of the allowable charge).

1.3.4.2 For TRICARE beneficiaries who are not enrolled in Medicare Part B because they are exempt from enrolling, TRICARE will process the outpatient claims as the primary payer assessing any applicable deductibles and cost-shares, in accordance with the TOM, Chapter 20, Section 3, paragraph 6.1.

Note: In order to achieve status as a TRICARE authorized provider, DVA facilities must comply with the provisions of the TPM, Chapter 11, Section 2.1.

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1.3.5 Services Provided By A Medicare At-Risk Plan

If the beneficiary is a member of a Medicare at-risk plan (for example, Medicare Plus Choice), TRICARE will pay 100% of the beneficiaries copay for covered services. A claim containing the required information must be submitted to obtain reimbursement.

1.3.6 Beneficiary Cost-Shares

Beneficiary costs shares shall be based on the network status of the provider. Where TRICARE is primary payer, cost-shares for services shall be based on those described in Chapter 2. Network discounts shall only be applied when the discount arrangement specifically contemplated the TFL population.

1.3.7 Application Of Catastrophic Cap

Only the actual beneficiary out-of-pocket liability remaining after TRICARE payments will be counted for purposes of the annual catastrophic loss protection.

1.4 End Stage Renal Disease (ESRD) in TRICARE beneficiaries less than 65 years of age. Medicare is the primary payer and TRICARE is the secondary payer for beneficiaries entitled to Medicare Part A and who have Medicare Part B coverage.

1.5 Pharmacy Claims. TRICARE cost-sharing of medications through a Medicare part D prescription drug plan is subject to the double coverage provisions found in 32 CFR 199.8.

2.0 TRICARE AND MEDICAID

Medicaid is essentially a welfare program, providing medical benefits for persons under various state welfare programs (such as Aid to Dependent Children) or who qualify by reason of being determined to be “medically indigent” based on a means test. In enacting Public Law 97-377, it was the intent of Congress that no class of TRICARE beneficiary should have to resort to welfare programs, and therefore, Medicaid was exempted from these double coverage provisions. Whenever a TRICARE beneficiary is also eligible for Medicaid, TRICARE is always the primary payer. In those instances where Medicaid extends benefits on behalf of a Medicaid eligible person who is subsequently determined to be a TRICARE beneficiary, TRICARE shall reimburse the appropriate Medicaid agency for the amount TRICARE would have paid in the absence of Medicaid benefits or the amount paid by Medicaid, whichever is less. See Chapter 1, Section 20.

3.0 MATERNAL AND CHILD HEALTH PROGRAM/INDIAN HEALTH SERVICE (IHS)

Eligibility for health benefits under either of these two Federal programs is not considered to be double coverage (see Section 1).

4.0 TRICARE AND THE DVA

Eligibility for health care through the DVA for a service-connected disability is not considered double coverage. If an individual is eligible for health care through the DVA and is also eligible for TRICARE, he/she may use either TRICARE or veterans benefits. In addition, at any time a beneficiary may get medically necessary care through TRICARE, even if the beneficiary has received some

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treatment for the same Episode Of Care (EOC) through the DVA. However, TRICARE will not duplicate payments made by or authorized to be made by the DVA for treatment of a service-connected disability.

5.0 TRICARE AND WORKER’S COMPENSATION

TRICARE benefits are not payable for work-related illness or injury which is covered under a Worker’s Compensation program. The TRICARE beneficiary may not waive his or her Worker’s Compensation benefits in favor of using TRICARE benefits. If a claim indicates that an illness or injury might be work related, the contractor will process the claim following the provisions as provided in TOM, Chapter 10, Section 5, paragraphs 5.0 and 6.0 and refer the claim to the Uniformed Service Claims Office for recovery, if appropriate.

6.0 TRICARE AND SUPPLEMENTAL INSURANCE PLANS

6.1 Not Considered Double Coverage

Supplemental plans (see Chapter 1, Section 26) or complementary insurance coverage is a health insurance policy or other health benefit plan offered by a private entity to a TRICARE beneficiary, that primarily is designed, advertised, marketed, or otherwise held out as providing payment for expenses incurred for services and items that are not reimbursed under TRICARE due to program limitations, or beneficiary liabilities imposed by law. TRICARE recognizes two types of supplemental plans, general indemnity plans and those offered through a direct service Health Maintenance Organization (HMO). Supplemental insurance plans are not considered double coverage. TRICARE benefits will be paid without regard to the beneficiary’s entitlement to supplemental coverage.

6.2 Income Maintenance Plans

Income maintenance plans pay the beneficiary a flat amount per day, week or month while the beneficiary is hospitalized or disabled. They usually do not specify a type of illness, Length-Of-Stay (LOS), or type of medical service required to qualify for benefits, and benefits are not paid on the basis of incurred expenses. Income maintenance plans are not considered double coverage. TRICARE will pay benefits without regard to the beneficiary’s entitlement to an income maintenance plan.

6.3 Other Secondary Coverage

Some insurance plans state that their benefits are payable only after payment by all government, Blue Cross/Blue Shield (BC/BS) and private plans to which the beneficiary is entitled. In some coverages, however, it provides that if the beneficiary has no other coverage, it will pay as a primary carrier. Such plans are double coverage under TRICARE law, regulation, and policy and are subject to the usual double coverage requirements.

7.0 SCHOOL COVERAGE - SCHOOL INFIRMARY

TRICARE benefits shall be paid for covered services provided to students by a school infirmary provided that the school imposes charges for the services on all students or on all students who are covered by health insurance.

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8.0 TRICARE AND PREFERRED PROVIDER ORGANIZATIONS (PPOs)

See Chapter 1, Section 25.

9.0 DOUBLE COVERAGE AND EXTENDED CARE HEALTH OPTION (ECHO)

All double coverage rules and procedures which apply to claims under the basic program are also to be applied to ECHO claims. All local resources must be considered and utilized before TRICARE benefits under the ECHO may be extended. If an ECHO beneficiary is eligible for other federal, state, or local assistance to the same extent as any other resident or citizen, TRICARE benefits are payable only for amounts left unpaid by the other program, up to the TRICARE maximums established in TPM, Chapter 9. The beneficiary may not waive available federal, state, or local assistance in favor of using TRICARE.

Note: The requirements of paragraph 9.0 notwithstanding, TRICARE is primary payer for medical services and items that are provided under Part C of the Individuals with Disabilities Education Act in accordance with the Individualized Family Service Plan (IFSP) and that are otherwise allowable under the TRICARE Basic Program or the ECHO.

10.0 PRIVATELY-PURCHASED, NON-GROUP COVERAGE

Privately-purchased, non-group health insurance coverage is considered double coverage.

11.0 LIABILITY INSURANCE

If a TRICARE beneficiary is injured as a result of an action or the negligence of a third person, the contractor must develop the claim(s) for potential Third Party Liability (TPL) (see the TOM, Chapter 10, Section 5). The contractor shall pursue the Government’s subrogation rights under the Federal Medical Care Recovery Act (FMCRA), if the other health insurance does not cover all expenses.

12.0 TRICARE AND PRE-PAID PRESCRIPTION PLANS

If the beneficiary has a “pre-paid prescription plan,” where the beneficiary pays only a “flat fee” no matter what the actual cost of the drug, the contractor shall cost-share the fee and not develop for the actual cost of the drug, since the beneficiary is liable only for the “fee.”

13.0 TRICARE AND STATE VICTIMS OF CRIME COMPENSATION PROGRAMS

Effective September 13, 1994, State Victims of Crime Compensation Programs are not considered double coverage. When a TRICARE beneficiary is also eligible for benefits under a State Victims of Crime Compensation Program, TRICARE is always the primary payer over the State Victims of Crime Compensation Programs.

14.0 SURROGATE ARRANGEMENTS

Contractual arrangements between a surrogate mother and adoptive parents are considered other coverage. For pregnancies in which the surrogate mother is a TRICARE beneficiary, services and supplies associated with antepartum care, postpartum care, and complications of pregnancy

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may be cost-shared only as a secondary payer, and only after the contractually agreed upon amount has been exhausted. This applies where contractual arrangements for payment include a requirement for the adoptive parents to pay all or part of the medical expenses of the surrogate mother as well as where contractual arrangements for payment do not specifically address reimbursement for the mother’s medical care. If brought to the contractor’s attention, the requirements of TOM, Chapter 10, Section 5, paragraph 2.10 would apply.

15.0 TRICARE AND FOREIGN MILITARY MEMBERS/FAMILY MEMBERS

Some countries with foreign military members stationed in the United States (U.S.) provide U.S. carrier issued commercial health insurance coverage to their members and family members, that when combined with TRICARE coverage as a second payer, attempts to limit their out-of-pocket expenses similar to their home country national health plan and/or reduces the foreign nation’s burden of reimbursing their members/family members for out-of-pocket health care costs. As such, claims for civilian outpatient services for foreign military members and family members require review for possible double coverage (not to include national health plan coverage from their home country). See Section 2 and TOM, Chapter 17, Section 3.

- END -

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008Index

Hospital Reimbursement (Continued)Determination Of Payment Amounts 6 5DRG Weighting Factors 6 6General Description Of System 6 2General 6 1Information Provided By TMA 6 9

Inpatient Mental Health Per Diem Payment System 7 1Locations Outside The 50 United States And The District Of Columbia 1 34Other Than Billed Charges 1 22Outpatient Services 1 24Payment When Only SNF Level Of Care Is Required 1 23

Hospital-BasedBirthing Center Reimbursement 10 1Birthing Room 1 32

I Chap Sec/AddInpatient Mental Health Per Diem Payment System 7 1Inpatient Rehabilitation Facilities (IRFs) 17 1Insulin 1 15Intensive Outpatient Program (IOP) Reimbursement 7 2

L Chap Sec/AddLaboratory Services 1 13Legal Obligation To Pay 1 27Legend Drugs 1 15Locality-Based Reimbursement Rate Waiver 5 2Long-Term Care Hospitals (LTCHs) 16 1

M Chap Sec/AddMaximum Allowable Charge For Breastfeeding Supplies 1 DMedical Errors 1 37Minimum Requirements For Reimbursement Of Per Capita Based (Or Alternative) State Vaccine Programs (SVPs) 1 C

H (CONTINUED) Chap Sec/Add N Chap Sec/AddNational Health Service Corps Physicians Of The Public Health Service 1 5Network Provider Reimbursement 1 1Newborn Charges 1 31Non-OPPS Facilities Reimbursement 9 1Nurse Practitioners 1 6

O Chap Sec/AddOASIS-B1 12 FObstetrical Care 1 18Office-Based Opioid Treatment (OBOT)l 13 1Opioid Treatment Programs Reimbursement 7 5Orthotics 1 11Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)

Billing And Coding Of Services Under APC Groups 13 2Claims Submission And Processing Requirements 13 4Development Schedule For TRICARE OCE/APC Quarterly Update 13 AGeneral 13 1Medical Review And Allowable Charge Review Under the OPPS 13 5Outpatient Code Editor (OCE)

No Government Pay List (NGPL) Quarterly Update Process 13 CNotification Process For Quarterly Updates 13 B

Prospective Payment Methodology 13 3Oxygen And Related Supplies 1 12

P Chap Sec/AddPartial Hospitalization Program (PHP) Reimbursement 7 2Participation Agreement For Hospice Program Services For TRICARE Beneficiaries 11 DPayment For Professional/Technical Components Of Diagnostic Services 5 4Payment Reduction 3 4Pharmacy Benefits Program - Cost-Shares 2 BPhysician Assistants 1 6Point Of Service (POS) Option 2 3Postoperative Pain Management-Epidural Analgesia 1 10

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TRICARE Reimbursement Manual 6010.58-M, February 1, 2008Index

Preferred Provider Organization (PPO) Reimbursement 1 25Prior to Implementation Of The Reasonable Cost Method for CAHs and Implementation of the OPPS, And Thereafter, For Services Not Otherwise Reimbursed Under Hospital OPPS

Ambulatory Surgical Center (ASC) 9 1Freestanding Partial Hospitalization Program (PHP) 7 2Outpatient Services 1 24

Partial Hospitalization Program (PHP) 7 2Processing And Payment Of Home Infusion Claims

Before January 30, 2012 3 6On Or After January 30, 2012 3 7

Professional Provider Reimbursement In Specified Locations Outside The 50 United States And The District Of Columbia 1 35Professional Services-Obstetrical Care 1 18Prosthetics 1 11Psychiatric Hospitals And Units Regional Specific Rates (FY 2017 - FY 2019) 7 A

R Chap Sec/AddReduction Of Payment For Noncompliance With Utilization Review Requirements 1 28Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume (FY 2017 - FY 2019) 7 AReimbursement

Administration 3 5Ambulatory Surgical Center (ASC) 9 1Birthing Center (Freestanding and Hospital-Based) 10 1Covered Services Provided By Individual Health Care Providers And Other Non-Institutional Health Care Providers 1 7Emergency Inpatient Admissions To Unauthorized Facilities 1 29Freestanding Ambulatory Surgical Center (ASC) 9 1Freestanding Partial Hospitalization Program (PHP) 7 2Hospital 3 2In Teaching Setting 1 4Individual Health Care Professionals 3 1Institutional Health Care Provider 3 2Intensive Outpatient Program (IOP) 7 2

P (CONTINUED) Chap Sec/AddReimbursement (Continued)

Mental Health And Substance Use Disorder (SUD) Treatment 7 2Network Provider 1 1Non-Institutional Health Care Providers 3 1Non-OPPS Facilities 9 1Opioid Treatment Programs 7 5Outpatient Services 1 24Partial Hospitalization Program (PHP) 7 2Physician Assistants, Nurse Practitioners, And Certified Psychiatric Nurse Specialists 1 6Preferred Provider Organization (PPO) 1 25Residential Treatment Center (RTC) 7 4Skilled Nursing Facility (SNF) 8 1State Vaccine Programs (SVPs) 1 38Substance Use Disorder Rehabilitation Facilities (SUDRFs) 7 3Travel Expenses For Specialty Care 1 30

Residential Treatment Center (RTC)Guidelines For The Calculation Of Individual Psychiatric RTC Per Diem Rates 7 BReimbursement 7 4

S Chap Sec/AddSkilled Nursing Facility (SNF)

Case-Mix Adjusted Federal RatesFY 2017 8 D (FY2017)FY 2018 8 D (FY2018)FY 2019 8 D (FY2019)

Example Of Computation of Adjusted PPS Rates And SNF Payment

FY 2017 8 B (FY2017)FY 2018 8 B (FY2018)FY 2019 8 B (FY2019)

Fact Sheet Regarding Consolidated Billing and Ambulance Services 8 CLetter To SNF Regarding Participation Agreement 8 GProspective Payment System (PPS) 8 2Reimbursement 8 1Resource Utilization Group-III (RUG-III) 8 AWage Indexes

Rural Areas (Based On CBSA Labor Market Areas)

FY 2017 8 F (FY2017)FY 2018 8 F (FY2018)FY 2019 8 F (FY2019)

R (CONTINUED) Chap Sec/Add

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Documents

PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE ...€¦ · when prescribed action has been taken, file this transmittal with basic document. hpod change 172 6010.58-m march 11,