tr15_160106.pdf

TRICARE Reimbursement Manual 6010.61-M, April 1, 2015

SUMMARY OF CHANGES

This change includes multiple clerical edits in addition to the changes specified below.

CHAPTER 1

1. Section 11. Added ‘durable equipment’ to entire section, including section title.

CHAPTER 2

2. Section 1.

a. Fiscal Year 2016 per diem for lower volume hospitals and units set at $229.

b. Clarified to read: Any TRICARE-eligible children of the former spouse will retain a legal familial relationship with the member or former member and shall be included in the member’s or former member’s family deductible.

CHAPTER 7

3. Section 1.

a. Fiscal Year 2016 inpatient mental health per diem amount set at $1,096.

b. Fiscal Year 2016 update factor for hospital-specific and regional per diems set at 2.4%.

c. Para 3.6.1.2.2. Updated the percentage of changes and the Deflator Factors, for years 2012 through 2014.

4. Addendum A. Updated the Table of Regional Specific Rates for Psychiatric Hospitals and Units with Low TRICARE Volume for FY 2014 - FY 2016. Added FY2016/Beneficiary Cost- Share: Beneficiary cost-share (other than active duty members) based on a regional per diem rate is the lower of $229 per day or 25% of the hospital billed charges, effective for services rendered on or after October 1, 2015.

CHAPTER 11

5. Section 2. Added Durable equipment to list supplies that are a part of the written plan of care and to description of hospice supplied medical appliances.

6. Section 4. Added durable equipment to description of hospice supplied medical appliances.

CHAPTER 12

7. Section 2. Changed Durable Medical Equipment to Durable Equipment.

1 January 6, 2016

CHAPTER 12 (Continued)

8. Section 4. Added language for mandated ICD-10-CM diagnoses codes.

9. Section 5. Added Durable Equipment language.

10. Section 6.

a. Clarified that the contractor’s claims systems shall assure accuracy of total charges billed, place the reimbursement amount for the RAP in FL 47 on the electronic claim, and not make any payment determinations based on submitted charge amounts.

b. Added language for mandated ICD-10-CM diagnoses codes.

11. Section 7. Clarified that outlier payment determinations are made in accordance with logic in the pricer.

CHAPTER 13

12. Section 2.

a. Updated language regarding APC payment for drugs and radiopharmaceuticals so it doesn’t require a manual change each year (paragraph 3.2.2.2.2).

b. Updated Partial Hospitalization Programs (PHPs) as of Calendar Year 2015 instead of 2008.

c. Added reference to Medicare Claims Processing Manual for PHP claims in hospitals subject to OPPS.

d. Revised exceptions to the policy of nonpayment for “inpatient only” procedures under OPPS.

13. Section 3.

a. Clarified that DHA uses the relative payment rates for each APC derived from CMS, with a reference to the CMS Claims Processing Manual for more information.

b. The conversion factor can be found in the CMS OPPS final rule which is published annually.

c. Status Indicator (SI) ‘J1’ added to the list of SIs eligible for outlier payment under

OPPS.

d. Added Durable equipment to description that includes DME.

e. Updated language regarding APC payment for drugs and radiopharmaceuticals so it doesn’t require a manual change each year throughout section.

f. HCPCS drug administration codes, APC and SI assignments moved to a web site.

2 January 6, 2016

CHAPTER 13 (Continued)

13. Section 3 (Continued).

g. Removed some language regarding Type B ED visits. Note: this change is on top of other changes that were only made to the T2017 version in an earlier amendment.

CHAPTER 14

14. Section 1.

a. Clarified Nursery and Labor/Delivery Adjustment (NLDA) reimbursement for Sole Community Hospitals.

b. Clarified that denied General Temporary Military Contingency Payment Adjustments (GTMCPA) requests do not require concurrence approval by the Director, DHA.

CHAPTER 15

15. Section 1.

a. Clarified payment for inpatient and outpatient services for Critical Access Hospitals (CAHs) under the reasonable cost method.

b. Clarified the CCR outlier reimbursement method and removed outdated language.

3 January 6, 2016

HPOS HPOB April 1, 2015

Revision:

The TRICARE Reimbursement Manual (TRM) 6010.61-M, in conjunction with the TRICARE Policy Manual (TPM), 6010.60-M, contains operational policy necessary to efficiently implement the Code of Federal Regulations at 32 CFR 199. This manual augments the 32 CFR 199 and must be used in conjunction for complete policy information, providing guidance, policy interpretation and decisions implementing TRICARE, including those policies and procedures applicable to the TRICARE Health Plan.

The Department of Defense (DoD) has a License Agreement with the American Medical Association (AMA) regarding the use of the Physician’s Current Procedural Terminology (CPT), a coding work of medical nomenclature developed by the AMA. In accordance with the terms of that Agreement, the DoD has agreed to:

1. Include a Copyright notice in every section that references CPT codes;

2. Specifically identify procedure codes as CPT procedure codes;

3. Use only short descriptions with CPT codes and delete all long descriptions; and

4. Italicize short descriptions wherever they are used and include a footnote stipulating that they are excerpted from the CPT.

The TRICARE Manuals provide instructions, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and the regulations and may not be interpreted in contradiction thereto.

John L. Arendale, Section Branch Chief Health Plan Operations Sections (HPOS) Branch

(HPOB)

Defense Health Agency (DHA)

Definitions are available in the Apr 2015 TRICARE Operations Manual (TOM), Appendix A.

Acronyms and Abbreviations are available at http://www._______________.

Foreword

Chapter 1

General

Revision:

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 (NHSC) Physicians Of The Public Health Service (PHS)

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 Professionals 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 Services Figure 1.14-1 Ground Ambulance Scenarios In Which The Beneficiary Dies Figure 1.14-2 Air Ambulance Scenarios in Which The Beneficiary Dies Figure 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

General Chapter 1 Section 11

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

Issue Date: December 29, 1982 Authority: 32 CFR 199.4(d)(3)(ii), (d)(3)(iii), (d)(3)(vii), and (d)(3)(viii) Revision:

1.0 APPLICABILITY

1.1 This policy is mandatory for DE, such as wheelchairs, iron lungs, and hospital beds.

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

2.0 ISSUE

How are claims for DE and DMEPOS to be reimbursed?

3.0 POLICY

3.1 Reimbursement for DE and DMEPOS is established by fee schedules. The fee schedule is referred to, all-inclusively, as the DMEPOS fee schedule. The maximum allowable amount is limited to the lower of the billed charge, the negotiated rate (network providers) or the DMEPOS fee schedule amount.

3.2 The DMEPOS fee schedule is categorized by state. The allowed amount shall be that which is in effect in the specific geographic location at the time covered services and supplies are provided to a beneficiary. For DMEPOS delivered to the beneficiary’s home, the home address is the controlling factor in pricing and the home address shall be used to determine the DMEPOS allowed amount.

3.3 Payment for an item of DE/Durable Medical Equipment (DME) may also take into consideration:

3.3.1 The lower of the total rental cost for the period of medical necessity or the reasonable purchase cost; and

3.3.2 Delivery charge, pick-up charge, shipping and handling charges, and taxes.

Chapter 1, Section 11

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

3.4 The fee schedule classifies most DMEPOS items into one of six categories.

3.4.1 Inexpensive or other routinely purchased DE/DME.

3.4.2 Items requiring frequent and substantial servicing.

3.4.3 Customized items.

3.4.4 Other prosthetic and orthotic devices.

3.4.5 Capped rental items.

3.4.6 Oxygen and oxygen equipment.

3.5 Inexpensive or routinely purchased DE/DME.

3.5.1 Payment for this type of equipment is for rental or lump sum purchase. The total payment may not exceed the actual charge of the fee for a purchase.

3.5.2 Inexpensive DE/DME. This category is defined as equipment whose purchase price does not exceed $150.

3.5.3 Other routinely purchased DE/DME. This category consists of equipment that is purchased at least 75% of the time.

3.5.4 Modifiers used in this category are as follows (not an all-inclusive list):

3.6 Items requiring frequent and substantial servicing.

3.6.1 Equipment in this category is paid on a rental basis only. Payment is based on the monthly fee schedule amounts until the medical necessity ends. No payment is made for the purchase of equipment, maintenance and servicing, or for replacement of items in this category.

3.6.2 Supplies and accessories are not allowed separately.

3.6.3 For oxygen and oxygen supplies see Section 12 and the TRICARE Policy Manual (TPM), Chapter 8, Section 10.1.

RR Rental

NU Purchase of new equipment. Only used if new equipment was delivered.

UE Purchase of used equipment. Used equipment that has been purchased or rented by someone before the current purchase transaction. Used equipment also includes equipment that has been used under circumstances where there has been no commercial transaction (e.g., equipment used for trial periods or as a demonstrator).

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

3.7 Certain customized items.

3.7.1 The beneficiary’s physician must prescribe the customized equipment and provide information regarding the patient’s physical and medical status to warrant the need for the equipment.

3.7.2 See the TPM, Chapter 9, Section 15.1 for further information regarding customization of

DME.

3.8 Capped rental items. Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 15 months or on a purchase option basis not to exceed a period of continuous use of 13 months.

3.9 Upgrade DE/DME (Deluxe, Luxury, or Immaterial Features).

3.9.1 The allowable charge for standard equipment or item of DE/DME may be applied toward any upgraded item, when the beneficiary chooses to upgrade a covered DE/DME, to include additional features that are intended primarily for comfort or convenience, or features beyond those required by the beneficiary’s medical condition. Under this arrangement, charges for an upgraded DE/DME are the sole responsibility of the beneficiary. Beneficiary’s cost-shares and deductible will apply to the basic

DE/DME.

3.9.2 The DE/DME provider is to identify non-payable upgrades to DE/DME using the appropriate Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers.

Example: A beneficiary requests an upgrade DE/DME - the DE/DME provider bills beneficiary for non-payable upgrade, modifier GA on first line for item that is provided and modifier GK on second line for item that is covered. TRICARE cost-shares medically necessary item only (GK line item). The claim line with GA modifier will be denied as not medically necessary with the beneficiary responsibility (PR) message on the Explanation of Benefits (EOB). The claim line with the GK modifier will continue through the usual claims processing.

3.9.3 When the beneficiary upgrades an item of DE/DME, the upgrade charge is not managed by TRICARE, but calculated by the provider or supplier issuing the equipment. As a result, upgraded charges, clerical or calculation errors in connection with the upgraded equipment are not subject to appeal but are subject to administrative review by the contractor upon request from the beneficiary.

Note: The upgrade charge is the difference between the provider’s or supplier’s charge for the deluxe or upgraded item, and the allowable charge amount for the “covered” (standard) item.

3.9.4 Upgraded items of DE/DME do not count toward the beneficiary’s catastrophic cap.

However, the beneficiary’s responsibility for the standard DE/DME equipment will count towards the catastrophic cap. Charges for deluxe or upgraded items are the beneficiary’s responsibility even after the out-of-pocket maximum has been met for covered services.

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

3.10 Rental fee schedule.

3.10.1 For the first three rental months, the rental fee schedule is calculated so as to limit the monthly rental of 10% of the average of allowed purchase prices on claims for new 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. After paying the rental fee schedule amount for 15 months, no further payment may be made except for payment for maintenance and servicing.

3.10.2 Modifiers used in this category are as follows:

3.10.3 Claims Adjudication Determinations.

3.10.3.1 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 physician’s 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

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

3.10.3.2 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.

3.10.4 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.

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

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

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

3.14 Reimbursement Rates.

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

3.14.2 The pricing for splints and casts is available at http://www.health.mil/rates and will be updated annually.

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

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

3.16 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 http://www.health.mil/rates http://www.health.mil/rates

Claims for Durable Equipment (DE) and Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS) beneficiary. Maintenance may be covered for patient owned-DME when such maintenance must be performed by an authorized technician.

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

3.17.1 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.

3.17.2 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.

4.0 EXCLUSIONS AND LIMITATIONS

4.1 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.

4.2 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.

4.3 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.

5.0 EFFECTIVE DATES

5.1 September 1, 2005, for the DMEPOS system.

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

- END -

Chapter 1, Section 14

Ambulance Services Healthcare Common Procedure Coding System (HCPCS) codes A0426 through A0429 subject to applicable beneficiary cost-sharing.

4.3 The TRICARE national allowable charge system CMAC reimbursement methodology used to reimburse professional services does not apply to ambulance claims. The above reimbursement guidelines are to be used by the contractors.

4.4 Itemization requirements are dictated by the particular HCPCS codes used in filing an ambulance claim.

Chapter 1 Section 18

Professional Services: Obstetrical Care

Issue Date: August 26, 1985 Authority: 32 CFR 199.4(c)(2)(xii) Copyright: CPT only © 2006 American Medical Association (or such other date of publication of CPT).

All Rights Reserved.

Revision:

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 POLICY

2.1 Obstetrical services are reimbursed as an all-inclusive global maternity professional fee which includes all professional services normally provided for routine antepartum care, vaginal delivery (with or without episiotomy, or forceps or breech delivery) and postpartum care.

2.2 The price for total (all-inclusive; global) obstetric care includes all attending physician or attending certified nurse-midwife services required during the course of the maternity episode.

Incidental activity (observation, preparation, coordination, administration) rendered by office staff in support of the obstetrical professional’s delivery of services are included in the price.

3.0 EXCEPTIONS

3.1 Hospital-Employed Provider

Line item charges for covered obstetrical services of a physician or certified nurse-midwife employed by (1) a DRG-exempt hospital is reimbursed on a billed-charge basis; by (2) a DRG hospital is reimbursed subject to the TRICARE-determined CHAMPUS Maximum Allowable Charge (CMAC) determination.

3.2 Partial Care Rendered

Separate billings for antepartum care or delivery or postpartum care may be reimbursed subject to the aggregate amount limitations for a given segment of care prescribed in paragraph 5.2.

Chapter 1, Section 18

Professional Services: Obstetrical Care

4.2 Billing. Charges for the technical and professional components of tests must be separately identified on the maternity care bill and the number of antepartum and postpartum office visits must be indicated.

4.3 Birthing center professional services. Reimbursement for professional services for maternity care and childbirth furnished by a TRICARE-authorized birthing center is included in the birthing center all-inclusive rate.

Note: The TRICARE national allowable charge CMAC system used to reimburse professional services discussed in Section 1 and Chapter 5, Sections 1 and 3 does not apply to birthing center claims.

The reimbursement guidelines as discussed in Chapter 10, Section 1 are to be used by the contractors.

5.0 LIMITATIONS

5.1 The billing of separate maternity care procedures is subject to rebundling to CPT procedure codes 59400 or 59510 when all-inclusive maternity care was provided by the same professional provider.

5.2 Office-based childbirth services. The allowable charge for all-inclusive maternity care and childbirth in a physician’s office or in a certified nurse-midwife’s office is limited to the established allowable-charge for professional services for all-inclusive maternity care plus the allowable-charges for supplies usually associated with an in-home delivery.

6.0 EXCLUSIONS

The following CPT procedures are excluded when billed separately:

6.1 No technical component of a diagnostic or laboratory test is included in the total obstetric care price.

6.2 Test-related charges by the attending professional. With the exception of medically necessary ultrasounds, no separate allowance may be made for the examination, analysis, interpretation, or application of diagnostic or laboratory test results by the attending obstetrician or attending certified nurse-midwife. These activities are considered to be the responsibility of the attending professional and included in the global fee of the attending obstetrical care professional. For maternity related ultrasounds, see the TRICARE Policy Manual (TPM), Chapter 5, Section 2.1.

- END -

99071 Patient Education Materials

99078 Group Health Education

Chapter 1, Section 33

Bonus Payments In Health Professional Shortage Areas (HPSAs)

3.1.6 The bonus payment is based solely on the amount paid for professional services.

Professional services are those that are paid by the professional CHAMPUS Maximum Allowable Charge (CMAC) file, excluding codes that are clinical laboratory services or that are entirely technical in nature.

Claims submitted for the technical component only of a service (i.e., have a -TC modifier), if a service can have both professional and technical components, are also ineligible for the HPSA bonus. Thus, all Durable Medical Equipment (DME DE), injectable drugs, vaccines, facility charges, supplies, etc., are not included in the paid amounts used to calculate the HPSA bonus. The professional service CMAC file’s documentation describes how codes can be detected which are considered entirely technical or clinical lab. Anesthesia services by physicians paid through the anesthesia Relative Value Unit (RVU) and Conversion Factor (CF) files are also to be included as eligible services for the HPSA bonus calculation. Services that are performed by physicians and are professional services (not supplies, drugs, or other such charges) but do not have CMACs may be included in the HPSA bonus calculation, also, such as unlisted or “not elsewhere specified” CPT codes 27599, 27899, 30999, etc.

3.1.7 Bonus payments apply under Prime, Extra, and Standard for services provided in medically underserved areas.

3.1.8 TRICARE Prime Remote (TPR) and Supplemental Health Care Program (SHCP) shall be included in the bonus payment process.

3.1.9 Under TRICARE For Life (TFL), only those claims where TRICARE is primary would qualify for the bonus payment.

3.1.10 For Other Health Insurance (OHI) claims, the bonus payment would apply, but only on the amount paid by the Government.

3.2 Scope Of Benefit

3.2.1 HPSA

3.2.1.1 An additional payment shall be made quarterly to physicians who qualify and provide services in medically underserved areas (HPSAs).

3.2.1.2 The bonus payment for HPSA, both primary care and mental health areas, is 10% of the amount actually paid, not 10% of the amount allowed, e.g., CMAC. The HPSA bonus payment only applies to physician’s, podiatrist’s, oral surgeon’s, and optometrist’s services rendered in these medically underserved areas. The modifier “AQ” effective January 1, 2006. As of October 1, 2013, the AQ modifier is no longer required except in those instances where zip codes do not fall entirely within a full county HPSA as noted in paragraph 3.2.1.11.

3.2.1.3 The bonus shall be calculated based on 10% of the amount actually paid a physician during a calendar quarter for services rendered in a medically underserved area.

3.2.1.4 Bonus payments are pass-through payments, non-financially underwritten payments.

3.2.1.5 The contractor shall sum all claim payments that qualify for the quarter and pay an additional 10% for the claims. There are no retroactive payments, adjustments or appeals, for obtaining a bonus payment. On or after October 1, 2013, the contractor requirements in paragraphs 3.2.1.11.1, 3.2.1.11.2, and 3.2.1.11.3 shall apply and serve as validation of the HPSA payment.

Chapter 1, Section 34

Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia

• The payment rate for each of the 18 diagnostic groups was the average allowed amount per day over all the ICD-9-CM codes in a diagnosis group, based upon the claim’s primary diagnosis, plus an add-on to reimburse for capital costs.

4.4.3.2 For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation:

• A rate setting methodology utilizing the first alpha character and two digits of a primary diagnosis code.

• Eighteen diagnosis groupings were defined and designed based on the groupings and definitions contained in the ICD-10-CM publication. For example, Group 1 is defined as ICD-10-CM codes A00 to B99, or Infectious and Parasitic Diseases. The first alpha character and two digits of a primary diagnosis code are utilized for placement into one of the 18 groups.

• The payment rate for each of the 18 diagnostic groups was the average allowed amount per day over all the ICD-10-CM codes in a diagnosis group, based upon the claim’s primary diagnosis, plus an add-on to reimburse for capital costs.

4.4.3.3 Group payments were calculated by dividing total allowed charges by total inpatient days for the group.

4.4.3.4 Once the 18 groupings were defined, certain unique admissions were identified for reimbursement separately from the 18 groupings. These are listed in Figure 1.34-3.

4.5 Payments

4.5.1 General. For services provided before the mandated date, as directed by HHS, for ICD-10 implementation, the per diem group payment rate will be based on the first three digits of the primary diagnosis code. For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation, the per diem group payment rate will be based on the first alpha character and two digits of the primary diagnosis code. The maximum amount allowed by TRICARE allowable charge and the amount reimbursed for hospital inpatient care shall be the lesser of:

• Actual billed charges for hospital inpatient care; or

• The TRICARE U.S. National per diem rate authorized under TRICARE, multiplied by the country specific index factor, is the country specific hospital per diem. This per diem is multiplied by the number of covered days of hospital inpatient care and equals the maximum amount allowed by TRICARE to be paid for the episode on inpatient care.

4.5.2 Only the primary diagnosis code, on the date of admission, will be taken into consideration when determining the group for a payment rate. Only one payment group can be assigned to each independent episode of inpatient care. For services provided before the mandated date, as directed by HHS, for ICD-10 implementation, each institutional claim for service reimbursement must contain a valid ICD-9-CM code or narrative description of services, and must be used to represent the primary

Chapter 1, Section 34

Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia diagnosis for inpatient admission. For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation, each institutional claim for service reimbursement must contain a valid ICD-10-CM code or narrative description of services, and must be used to represent the primary diagnosis for inpatient admission. If a valid diagnosis code or narrative description is not supplied by the institutional provider it must be developed and supported by the overseas claims processor.

Development of an institutional claim should contain the necessary elements to satisfy TRICARE Encounter Data (TED) requirements.

4.6 Beneficiary - Change in Eligibility Status

Since payment is on a per diem basis, the hospital claim for services shall be paid for the days the beneficiary is TRICARE eligible and denied for the days the beneficiary is not TRICARE eligible.

4.7 Beneficiary Cost-Shares

Inpatient cost-shares as contained in Chapter 2, Section 1, for non-Diagnosis Related Group (DRG) facilities shall be applicable to TRICARE’s the hospital allowable charge authorized under

TRICARE.

4.8 Updating Payment Rates

4.8.1 For services provided before the mandated date, as directed by HHS, for ICD-10 implementation, additions, changes, revisions, or deletions to the ICD-9-CM codes or country specific index shall be communicated to the overseas claims processor and be considered as routine updates to this payment system and processed under TRICARE Operations Manual (TOM), Chapter 1, Section 4, paragraph 2.4.

4.8.2 For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation, additions, changes, revisions, or deletions to the ICD-10-CM codes or country specific index shall be communicated to the overseas claims processor and be considered as routine updates to this payment system and processed under TOM, Chapter 1, Section 4, paragraph 2.4.

4.9 The overseas claims processor shall maintain the current year and two immediate past years’ iterations of the TRICARE U.S. National per diems authorized under TRICARE and the country specific index factors.

4.10 There is no TRICARE waiver process applicable to hospitals in specified locations outside the 50 U.S. and the District of Columbia for institutional inpatient rates.

Chapter 1, Section 35

Professional Provider Reimbursement In Specified Locations Outside The 50 United States (U.S.) And The District Of Columbia conversion and therefore parity between the U.S. and the specific country in the purchasing of the same amount and type of medical services. TRICARE is utilizing the World Bank’s International Comparison Program country specific index as provided in Figure 1.35-1.

4.4 Updating Professional Payment Rates

Annually, the Policy and Statistical Analysis Services contractor shall calculate the U.S. National CMAC rates. The data will contain each CPT code, a short description, a U.S. National payment rate, as well as the effective date. On an annual basis, the U.S. National CMAC may increase or decrease as determined by TRICARE. This contractor shall separately supply to the Defense Health Agency (DHA) the country specific index every year or as dictated by the World Bank’s International Comparison program or as determined by TRICARE, which will be included in Figure 1.35-1. The above contractor shall also provide the country specific index adjusted CMAC files, and any updates or corrections, electronically to DHA, which will be provided to the overseas claims processor at least annually, or as specifics may dictate. For those codes that contain a technical as well as professional component, each component shall have a separate supplied payment rate. Updates, additions, changes, revisions or deletions to the CPT codes or country specific index or CMACs will be communicated to the overseas claims processor and shall be considered as routine updates to this payment system and processed under TRICARE Operations Manual (TOM), Chapter 1, Section 4, paragraph 2.4. The adjusted per diems will be available at: http://www.tricare.mil/tma/foreignfee/.

4.5 Beneficiary Eligibility - Change in Eligibility Status

Since the payment is on a date of service basis, the professional, and other charges shall be paid for all dates of service that the beneficiary is TRICARE eligible and denied for all dates of services the beneficiary is not TRICARE eligible.

4.6 Beneficiary Cost-Shares

Beneficiary cost-shares are contained in Chapter 2, Section 1, and shall be applicable to TRICARE’s applicable professional allowable charges.

4.7 The overseas claims processor and the overseas contractor shall maintain the current year and two immediate past years’ iterations of the country specific index adjusted CMAC CPT rates.

4.8 Ancillary Services

Effective January 1, 2013, ancillary services in Panama shall be paid using the lesser of billed charges or 250% of the U.S. National CMAC.

http://www.tricare.mil/tma/foreignfee/ http://www.tricare.mil/tma/foreignfee/

Chapter 1 Section 36

Forensic Examinations Following Sexual Assault or Domestic Violence

Issue Date: October 29, 2009 Authority: 32 CFR 199.4(e)(27) Revision:

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 Defense Health Agency (DHA) and specifically included in the network provider agreement.

2.0 ISSUE

How are forensic examinations following sexual assault or domestic violence to be reimbursed?

3.0 POLICY

3.1 Forensic examinations, including evidence collection kits, are covered when provided in Civilian Health Care (CHC) facilities following a sexual assault or domestic violence.

3.2 Claims must contain one or more diagnosis codes that indicate the purpose of the visit or inpatient admission is directly related to services for an examination or treatment resulting from sexual assault or domestic violence.

3.3 Reimbursement for forensic examinations and evidence collection kits will shall be made according to the appropriate type of provider, type of service, and place of service in effect at the time services are rendered.

4.0 EFFECTIVE DATE

October 17, 2006.

Chapter 1, Section 37

Medical Errors

2.6.2 Claim lines submitted with one of the above HCPCS modifiers will shall be denied as services that are not medically necessary. Claim lines for medically necessary services (i.e., without one of the above modifiers shall be allowed).

2.7 Within five business days of receiving a claim for a surgical error, contractors will shall begin to review beneficiary history for related claims as appropriate (both claims already received and processed and those received subsequent to the notification of the surgical error).

2.7.1 In addition, contractors will shall establish a mechanism to identify incoming claims that have the potential to be related.

2.7.2 When the contractor identifies such claims, it will the contractor shall take appropriate action to deny such claims and to recover any overpayments on claims already processed.

2.8 Appeals and Hearings

Medical error denials are appealable. The contractor is required to follow the requirements outlined in 32 CFR 199.10 and the TRICARE Operations Manual (TOM), Chapter 13 related to the appeals and hearing process.

Chapter 2, Section 1

Cost-Shares And Deductibles

1.1.6.1.1.3 A Civilian Health Care (CHC) provider may voluntarily waive, in whole or in part, the cost-share and/or deductible of Active Duty Family Members (ADFMs) if the provider certifies in writing that the amount charged the federal Government for such health care was not increased above the amount that the health care provider would have charged the federal Government for such health care had the payment not been waived.

1.1.6.1.1.3.1 The legislation only provides a temporary exemption to the cost-sharing provisions. Once the President officially proclaims an end to the “Persian Gulf conflict”, the cost-sharing provision will be reinstated.

1.1.6.1.1.3.2 The legislation will does not require modification of the existing claims processing guidelines. The contractors will shall process the claims normally, reflecting the appropriate deductible, cost-share, and catastrophic cap on the claims history, payment records, TRICARE Explanation of Benefits (EOB), etc. The waiver of cost-sharing is between the ADFM and the provider and does not affect the contractor’s claims processing procedures, except as prescribed in the Program Integrity provisions in the TRICARE Operations Manual (TOM), Chapter 13.

1.1.6.1.1.3.3 The waiver of cost-sharing will be is based on the dates of care/service.

1.1.6.1.1.3.4 The waiver applies to both the Basic Program and the ECHO and is applicable to both inpatient and outpatient care.

1.1.6.1.1.3.5 The waiver of cost-sharing only applies to family members of active duty personnel.

The other categories of TRICARE beneficiaries are still subject to the cost-sharing and deductible requirements set forth in 10 USC 1079 and 1086.

1.1.6.1.2 The exception to the cost-sharing requirements is effective for services rendered from August 2, 1990, until the date the “Persian Gulf conflict” ends as prescribed by Presidential proclamation or by law.

1.1.6.2 Operation Joint Endeavor

1.1.6.2.1 Under legislation passed for Operation Joint Endeavor, the TRICARE Standard deductible has been waived for family members of certain reserve members called to active duty.

However, this provision does not provide for voluntary waiver of cost-shares or the deductibles by providers allowed under Operation Desert Storm. If the family is enrolled in TRICARE Prime, the deductible for POS is not waived for this provision.

1.1.6.2.2 The exception to the deductible requirements under Operation Joint Endeavor for TRICARE Standard and Extra is effective for services rendered from December 8, 1995 until such time as Executive Order 12982 expires.

1.1.6.3 Operation Noble Eagle/Operation Enduring Freedom

1.1.6.3.1 The TRICARE Standard and Extra deductible is waived for family members of members of the reserves or National Guard who have been ordered to active duty in support of operations that result from the terrorist attacks on the World Trade Center (WTC) and the Pentagon on September 11, 2001.

Cost-Shares And Deductibles

1.1.6.3.2 The cost-share is partially waived in certain cases for these beneficiaries. On claims from non-participating professional providers for services rendered to Standard beneficiaries, the allowable amount is the lesser of the billed charge or the balance billing limit (115%) of the CHAMPUS Maximum Allowable Charge (CMAC)). In these cases, the cost-share is 20% of the lesser of the CMAC or the billed charge, and the cost-share for any amounts over the CMAC that are allowed is waived. Any amounts that are allowed over the CMAC will be paid entirely by TRICARE.

1.1.6.4 For Certain Reservists

The Defense Health Agency (DHA), may waive the individual or family deductible for family members of a Reserve Component (RC) member who is called or ordered to active duty for a period of more than 30 days but less than one year in support of a contingency operation. For this purpose, a RC member is either a member of the reserves or National Guard member who is called or ordered to full-time federal National Guard duty. A contingency operation is defined in 10 United States Code (USC) 101(a)(13). Also, for this purpose a family member is a lawful husband or wife of the member or an eligible child.

1.2 TRICARE Prime

1.2.1 Copayments and enrollment fees under TRICARE Prime are subject to review and annual updating. See Addendum A for additional information on the benefits and costs. In accordance with Section 752 of the National Defense Authorization Act, Public Law 106-398, for services provided on or after April 1, 2001, a $0 copayment shall be charged to TRICARE Prime ADFMs of Service members who are enrolled in TRICARE Prime. Pharmacy copayments and POS charges are not waived by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2001.

1.2.2 In instances where the CMAC or allowable charge is less than the copayment shown on Addendum A, network providers may only collect the lower of the allowable charge or the applicable copayment.

1.2.3 The TRICARE Prime copayment requirement for emergency room services is on a PER VISIT basis; this means that only one copayment is applicable to the entire emergency room episode, regardless of the number of providers involved in the patient’s care and regardless of their status as network providers.

1.2.4 Prime enrollees have no copayments for the ancillary services in the categories listed below (normal referral and authorization provisions apply). Current Procedural Terminology (CPT) code ranges are given; however, these codes are not all-inclusive. The most up-to-date codes should be utilized to identify services within each category, in accordance with the TOM, Chapter 1, Section 4.

Additionally, listing the code ranges does not imply coverage; the codes just provide the broad range of services that are not subject to copayments under this provision:

1.2.4.1 Diagnostic radiology and ultrasound services included in the CPT procedure code range from 70010-76999, or any other code for associated contrast media;

1.2.4.2 Diagnostic nuclear medicine services included in the CPT procedure code range from 78012-78999;

Cost-Shares And Deductibles

1.2.4.3 Pathology and laboratory services included in the CPT procedure code range from 80047- 89398; G0461-G0462 (during 2014); and

1.2.4.4 Cardiovascular studies included in the CPT procedure code range from 93000-93355.

1.2.4.5 Venipuncture included in the CPT procedure code range from 36400-36425.

1.2.4.6 Collection of blood specimens in the CPT procedure codes 36591 and 36592.

1.2.4.7 Fetal monitoring for CPT procedure codes 59020, 59025, and 59050.

Note: Multiple discounting will not be applied to the following CPT procedure codes for venipuncture, fetal monitoring, and collection of blood specimens; 36400-36425, 36591, 36592, 59020, 59025, and 59050.

1.2.5 Point of Service option. See Section 3.

1.3 Basic Program: TRICARE Standard

1.3.1 Deductible Amount: Outpatient Care

1.3.1.1 Active Duty Sponsor in Pay Grade E-4 or Below

1.3.1.1.1 Deductible, Individual: Each beneficiary is liable for the first fifty dollars ($50.00) of the TRICARE-determined allowable amount on claims for care provided in the same fiscal year.

1.3.1.1.2 Deductible, Family: The total deductible amount for all members of a family with the same sponsor during one fiscal year shall not exceed one hundred dollars ($100.00).

1.3.1.2 All TRICARE Beneficiaries Except Family Members of Active Duty Sponsors in Pay Grade E-4 or Below

1.3.1.2.1 Deductible, Individual: Each beneficiary is liable for the first $150.00 of the TRICARE-determined allowable amount on claims for care provided in the same fiscal year.

1.3.1.2.2 Deductible, Family: The total deductible amount for all members of a family with the same sponsor during one fiscal year shall not exceed $300.00.

1.3.1.3 TRICARE-Approved Ambulatory Surgery Centers (ASCs), Birthing Centers, or Partial Hospitalization Programs (PHPs)

1.3.1.4 No deductible shall be applied to allowable amounts for services or items rendered to ADFMs or authorized North Atlantic Treaty Organization (NATO) family members.

1.3.1.5 Allowable Amount Does Not Exceed Deductible Amount. If fiscal year allowable amounts for two or more beneficiary members of a family total less than $100.00 (or $300.00 if paragraph 1.3.1.2, applies), and no one beneficiary’s allowable amounts exceed $50.00 (or $150.00 if paragraph 1.3.1.2 applies), neither the family nor the individual deductible will have been met and no TRICARE benefits are payable.

Cost-Shares And Deductibles

1.3.3.2.2 Other Beneficiaries: For services exempt from the DRG-based payment system and the mental health per diem payment system and services provided by institutions other than hospitals (i.e., Residential Treatment Centers (RTCs)), the cost-share shall be 25% of the allowable charges.

1.3.3.3 Cost-Shares: Maternity

1.3.3.3.1 Determination. Maternity care cost-share shall be determined as follows:

1.3.3.3.1.1 Inpatient cost-share formula applies to maternity care ending in childbirth in, or on the way to, a hospital inpatient childbirth unit, and for maternity care ending in a non-birth outcome not otherwise excluded.

Note: Inpatient cost-share formula applies to prenatal and postnatal care provided in the office of a civilian physician or certified nurse-midwife in connection with maternity care ending in childbirth or termination of pregnancy in, or on the way to, a Military Treatment Facility (MTF)/Enhanced Multi- Service Market (eMSM) inpatient childbirth unit. ADFMs pay a per diem charge (or a $25.00 minimum charge) for an admission and there is no separate cost-share for them for separately billed professional charges or prenatal or postnatal care.

1.3.3.3.1.2 Ambulatory surgery cost-share formula applies to maternity care ending in childbirth in, or on the way to, a birthing center to which the beneficiary is admitted, and from which the beneficiary has received prenatal care, or a hospital-based outpatient birthing room.

1.3.3.3.1.3 Outpatient cost-share formula applies to maternity care which terminates in a planned childbirth at home.

1.3.3.3.1.4 Otherwise covered medical services and supplies directly related to “complications of pregnancy”, as defined in the Regulation, will shall be cost-shared on the same basis as the related maternity care for a period not to exceed 42 days following termination of the pregnancy and thereafter cost-shared on the basis of the inpatient or outpatient status of the beneficiary when medically necessary services and supplies are received.

1.3.3.3.2 Otherwise authorized services and supplies related to maternity care, including maternity related prescription drugs, shall be cost-shared on the same basis as the termination of pregnancy.

FIGURE 2.1-1 UNIFORMED SERVICES HOSPITAL DAILY CHARGE AMOUNTS

PERIOD DAILY CHARGE

October 1, 2011 - September 30, 2012 (for ADFMs not enrolled in Prime) $17.05

October 1, 2012 - September 30, 2013 (for ADFMs not enrolled in Prime) $17.35

October 1, 2013 - September 30, 2014 (for ADFMs not enrolled in Prime) $17.65

October 1, 2014 - September 30, 2015 (for ADFMs not enrolled in Prime) $17.80

Use the daily charge (per diem rate) in effect for each day of the stay to calculate a cost-share for a stay which spans periods.

Cost-Shares And Deductibles

1.3.3.3.3 Claims for pregnancy testing are shall be cost-shared on an outpatient basis when the delivery is on an inpatient basis.

1.3.3.3.4 Where the beneficiary delivers in a professional office birthing suite located in the office of a physician…