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TRICARE Program Manuals - 2021 Edition (T-5)
TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Policy Manual 6010.63-M, April 2021
TRICARE Reimbursement Manual 6010.64-M, April 2021
TRICARE Systems Manual 7950.4-M, April 2021
TRICARE Program Manuals - 2015 Edition (T-2017)
TRICARE Operations Manual 6010.59-M, April 2015
TRICARE Policy Manual 6010.60-M, April 2015
TRICARE Reimbursement Manual 6010.61-M, April 2015
TRICARE Systems Manual 7950.3-M, April 2015
Other Manuals
32 CFR 199 (DHA Version), December 2016
DoD Women, Infants, and Children (WIC) Overseas Program Policy Manual, July 2017
Duplicate Claims System (DCS) User Guide, June 2017
10 USC 55 (DHA Version), January 2007
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TRICARE Reimbursement Manual 6010.61-M, April 2015
Manual Change History
TRICARE Reimbursement Manual 6010.61-M, April 2015
Foreword
Change 42 (September 27, 2019)
Change 21 (May 30, 2018)
Baseline (April 1, 2015)
Chap 1 -- General
Change 57 (April 9, 2021)
Change 54 (February 3, 2021)
Change 42 (September 27, 2019)
Change 35 (March 19, 2019)
Change 34 (March 12, 2019)
Change 11 (November 30, 2017)
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Sect 1 -- Network Provider Reimbursement
Baseline (April 1, 2015)
Sect 2 -- Accommodation Of Discounts Under Provider Reimbursement Methods
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 3 -- Claims Auditing Software
Baseline (April 1, 2015)
Sect 4 -- Reimbursement In Teaching Setting
Baseline (April 1, 2015)
Sect 5 -- National Health Service Corps (NHSC) Physicians Of The Public Health Service (PHS)
Baseline (April 1, 2015)
Sect 6 -- Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)
Baseline (April 1, 2015)
Sect 7 -- Reimbursement Of Covered Services Provided By Individual Health Care Providers And Other Non-Institutional Health Care Providers
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Sect 8 -- Economic Interest In Connection With Mental Health Admissions
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Sect 9 -- Anesthesia
Baseline (April 1, 2015)
Sect 10 -- Postoperative Pain Management - Epidural Analgesia
Baseline (April 1, 2015)
Sect 11 -- Claims for Durable Equipment (DE) And Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)
Change 60 (June 30, 2021)
Change 34 (March 12, 2019)
Change 9 (November 9, 2017)
Baseline (April 1, 2015)
Sect 12 -- Oxygen And Related Supplies
Baseline (April 1, 2015)
Sect 13 -- Laboratory Services
Baseline (April 1, 2015)
Sect 14 -- Ambulance Services
Change 66 (January 6, 2023)
Change 41 (September 20, 2019)
Change 27 (October 19, 2018)
Change 19 (May 18, 2018)
Baseline (April 1, 2015)
Sect 15 -- Legend Drugs And Insulin
Change 44 (December 13, 2019)
Change 4 (August 2, 2017)
Baseline (April 1, 2015)
Sect 16 -- Surgery
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 17 -- Assistant Surgeons
Change 48 (April 17, 2020)
Baseline (April 1, 2015)
Sect 18 -- Professional Services: Obstetrical Care
Baseline (April 1, 2015)
Sect 19 -- Charges For Provider Administrative Expenses
Baseline (April 1, 2015)
Sect 20 -- State Agency Billing
Change 70 (June 12, 2023)
Baseline (April 1, 2015)
Sect 21 -- Hospital Reimbursement - Billed Charges Set Rates
Baseline (April 1, 2015)
Sect 22 -- Hospital Reimbursement - Other Than Billed Charges
Baseline (April 1, 2015)
Sect 23 -- Hospital Reimbursement - Payment When Only Skilled Nursing Facility (SNF) Level Of Care Is Required
Baseline (April 1, 2015)
Sect 24 -- Hospital Reimbursement - Outpatient Services
Change 71 (August 1, 2023)
Change 5 (August 23, 2017)
Baseline (April 1, 2015)
Sect 25 -- Preferred Provider Organization (PPO) Reimbursement
Baseline (April 1, 2015)
Sect 26 -- Supplemental Insurance
Baseline (April 1, 2015)
Sect 27 -- Legal Obligation To Pay
Baseline (April 1, 2015)
Sect 28 -- Reduction Of Payment For Noncompliance With Utilization Review Requirements
Change 41 (September 20, 2019)
Change 10 (November 15, 2017)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 29 -- Reimbursement Of Emergency Inpatient Admissions To Unauthorized Facilities
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Sect 30 -- Reimbursement Of Travel Expenses For Specialty Care
Change 59 (May 26, 2021)
Change 36 (April 24, 2019)
Change 17 (April 30, 2018)
Baseline (April 1, 2015)
Sect 31 -- Newborn Charges
Baseline (April 1, 2015)
Sect 32 -- Hospital-Based Birthing Room
Baseline (April 1, 2015)
Sect 33 -- Bonus Payments In Health Professional Shortage Areas (HPSAs)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 34 -- Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia
Change 82 (August 6, 2024)
Change 76 (January 9, 2024)
Change 66 (January 6, 2023)
Change 56 (April 2, 2021)
Change 45 (March 13, 2020)
Change 30 (January 15, 2019)
Change 14 (February 6, 2018)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States (U.S.) And The District Of Columbia
Change 82 (August 6, 2024)
Change 66 (January 6, 2023)
Change 21 (May 30, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 36 -- Forensic Examinations Following Sexual Assault or Domestic Violence
Baseline (April 1, 2015)
Sect 37 -- Medical Errors
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Sect 38 -- Reimbursement of State Vaccine Programs (SVPs)
Change 70 (June 12, 2023)
Change 37 (June 18, 2019)
Change 25 (August 15, 2018)
Change 11 (November 30, 2017)
Baseline (April 1, 2015)
Sect 39 -- CHAMPUS Maximum Allowable Charge (CMAC) For Banked Donor Milk (BDM)
Change 45 (March 13, 2020)
Change 35 (March 19, 2019)
Baseline (April 1, 2015)
Sect 40 -- Organ Acquisition Costs
Change 51 (December 18, 2020)
Change 42 (September 27, 2019)
Baseline (April 1, 2015)
Sect 41 -- Temporary Reimbursement Changes in Response to Coronavirus Disease 2019 (COVID-19) Pandemic
Change 79 (June 4, 2024)
Change 66 (January 6, 2023)
Change 54 (February 3, 2021)
Baseline (April 1, 2015)
Addendum A -- Sample State Agency Billing Agreement
Baseline (April 1, 2015)
Addendum B -- Figures
Baseline (April 1, 2015)
Addendum C -- Minimum Requirements For Reimbursement Of Per Capita State (Or Alternative) State Vaccine Programs (SVPs)
Change 11 (November 30, 2017)
Baseline (April 1, 2015)
Addendum D -- Maximum Allowable Charge For Breastfeeding Supplies
Change 60 (June 30, 2021)
Change 34 (March 12, 2019)
Baseline (April 1, 2015)
Addendum E -- Controls for Excessive Charges For Services, And Professional Durable Medical Equipment, Prosthetics, Orthotics, And Supplies/Parenteral And Enteral Nutrition (DMEPOS/PEN) Services Without Established Rates
Change 80 (July 18, 2024)
Baseline (April 1, 2015)
Chap 2 -- Beneficiary Liability
Change 52 (December 24, 2020)
Change 43 (November 27, 2019)
Change 22 (June 15, 2018)
Change 18 (May 3, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 1 -- Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries
Change 79 (June 4, 2024)
Change 76 (January 9, 2024)
Change 66 (January 6, 2023)
Change 61 (August 5, 2021)
Change 58 (April 20, 2021)
Change 52 (December 24, 2020)
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 32 (February 8, 2019)
Change 29 (December 27, 2018)
Change 28 (November 6, 2018)
Change 26 (September 14, 2018)
Change 22 (June 15, 2018)
Change 16 (March 7, 2018)
Change 10 (November 15, 2017)
Change 8 (October 27, 2017)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 2 -- Cost-Shares And Deductibles For TRICARE Services Received On Or After January 1, 2018
Change 72 (August 7, 2023)
Change 66 (January 6, 2023)
Change 65 (September 16, 2022)
Change 55 (March 26, 2021)
Change 52 (December 24, 2020)
Change 49 (June 9, 2020)
Change 29 (December 27, 2018)
Change 28 (November 6, 2018)
Change 26 (September 14, 2018)
Change 22 (June 15, 2018)
Change 12 (January 26, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 3 -- Catastrophic Loss Protection For TRICARE Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018, By TRICARE For Life (TFL) Beneficiaries
Change 61 (August 5, 2021)
Change 38 (June 28, 2019)
Change 26 (September 14, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 4 -- Catastrophic Loss Protection For Services Rendered On Or After January 1, 2018
Change 40 (August 30, 2019)
Change 26 (September 14, 2018)
Change 22 (June 15, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 5 -- Point Of Service (POS) Option
Change 66 (January 6, 2023)
Change 26 (September 14, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 6 -- Waivers of Cost-Shares and Deductibles
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 7 -- Temporary Waivers of Copayments and Cost-Shares (Including Deductibles) in Response to Coronavirus 2019 (COVID-19) Pandemic
Change 64 (August 3, 2022)
Change 52 (December 24, 2020)
Baseline (April 1, 2015)
Addendum A -- Benefits And Beneficiary Payments Under The TRICARE Program For Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries
Change 73 (August 21, 2023)
Change 66 (January 6, 2023)
Change 22 (June 15, 2018)
Change 12 (January 26, 2018)
Change 10 (November 15, 2017)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Addendum B -- Pharmacy Benefits Program - Cost-Shares
Change 68 (May 3, 2023)
Change 43 (November 27, 2019)
Change 21 (May 30, 2018)
Change 18 (May 3, 2018)
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 3 -- Operational Requirements
Baseline (April 1, 2015)
Sect 1 -- Reimbursement Of Individual Health Care Professionals And Other Non-Institutional Health Care Providers
Change 76 (January 9, 2024)
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Sect 2 -- Hospital And Other Institutional Reimbursement
Baseline (April 1, 2015)
Sect 3 -- Discounts
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Sect 4 -- Payment Reduction
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Sect 5 -- Reimbursement Administration
Baseline (April 1, 2015)
Sect 6 -- Processing And Payment Of Home Infusion Claims
Change 70 (June 12, 2023)
Change 4 (August 2, 2017)
Baseline (April 1, 2015)
Sect 7 -- No Government Pay Procedure Codes
Change 37 (June 18, 2019)
Change 21 (May 30, 2018)
Baseline (April 1, 2015)
Chap 4 -- Double Coverage
Baseline (April 1, 2015)
Sect 1 -- Double Coverage
Change 81 (August 2, 2024)
Change 66 (January 6, 2023)
Change 41 (September 20, 2019)
Baseline (April 1, 2015)
Sect 2 -- Double Coverage Review And Processing Of Claims
Change 81 (August 2, 2024)
Change 26 (September 14, 2018)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 3 -- Coordination Of Benefits (COB)
Change 10 (November 15, 2017)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 4 -- Specific Double Coverage Actions
Change 70 (June 12, 2023)
Change 41 (September 20, 2019)
Change 34 (March 12, 2019)
Change 26 (September 14, 2018)
Change 21 (May 30, 2018)
Change 19 (May 18, 2018)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 5 -- Allowable Charges
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Providers
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Sect 2 -- Locality-Based Reimbursement Rate Waiver
Baseline (April 1, 2015)
Sect 3 -- CHAMPUS Maximum Allowable Charges (CMAC)
Change 66 (January 6, 2023)
Change 21 (May 30, 2018)
Change 4 (August 2, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 4 -- Payment For Professional/Technical Components Of Diagnostic Services
Change 7 (October 24, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 6 -- Diagnosis Related Groups (DRGs)
Change 53 (January 8, 2021)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General)
Baseline (April 1, 2015)
Sect 2 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General Description Of System)
Change 72 (August 7, 2023)
Baseline (April 1, 2015)
Sect 3 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Basis Of Payment)
Change 41 (September 20, 2019)
Change 37 (June 18, 2019)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Sect 4 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Applicability Of The DRG System)
Change 32 (February 8, 2019)
Change 5 (August 23, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 5 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Determination Of Payment Amounts)
Baseline (April 1, 2015)
Sect 6 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (DRG Weighting Factors)
Baseline (April 1, 2015)
Sect 7 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjusted Standardized Amounts (ASAs))
Change 84 (October 16, 2024)
Change 79 (June 4, 2024)
Change 76 (January 9, 2024)
Change 66 (January 6, 2023)
Change 58 (April 20, 2021)
Change 44 (December 13, 2019)
Change 32 (February 8, 2019)
Change 16 (March 7, 2018)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 8 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts)
Change 79 (June 4, 2024)
Change 76 (January 9, 2024)
Change 66 (January 6, 2023)
Change 58 (April 20, 2021)
Change 47 (April 8, 2020)
Change 45 (March 13, 2020)
Change 44 (December 13, 2019)
Change 41 (September 20, 2019)
Change 37 (June 18, 2019)
Change 32 (February 8, 2019)
Change 26 (September 14, 2018)
Change 23 (July 3, 2018)
Change 21 (May 30, 2018)
Change 16 (March 7, 2018)
Change 5 (August 23, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 9 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Information Provided By Defense Health Agency (DHA))
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Sect 10 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Charges To Beneficiaries)
Change 66 (January 6, 2023)
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Sect 11 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (New Technology Add-On Payments (NTAPs))
Change 78 (May 20, 2024)
Change 74 (September 8, 2023)
Change 66 (January 6, 2023)
Change 56 (April 2, 2021)
Change 53 (January 8, 2021)
Baseline (April 1, 2015)
Sect 12 -- Hospital Reimbursement - Hospital Value-Based Purchasing (HVBP)
Change 79 (June 4, 2024)
Baseline (April 1, 2015)
Addendum A -- Health Benefit Program Agreement
Baseline (April 1, 2015)
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2015
Baseline (April 1, 2015)
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2016 And Beyond
Change 79 (June 4, 2024)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2015
Baseline (April 1, 2015)
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2016 And Beyond
Change 79 (June 4, 2024)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Chap 7 -- Mental Health
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 32 (February 8, 2019)
Change 25 (August 15, 2018)
Change 16 (March 7, 2018)
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Hospital Reimbursement - TRICARE Inpatient Mental Health Per Diem Payment System
Change 83 (August 20, 2024)
Change 79 (June 4, 2024)
Change 58 (April 20, 2021)
Change 51 (December 18, 2020)
Change 45 (March 13, 2020)
Change 44 (December 13, 2019)
Change 37 (June 18, 2019)
Change 32 (February 8, 2019)
Change 16 (March 7, 2018)
Change 10 (November 15, 2017)
Change 5 (August 23, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 2 -- Partial Hospitalization Program (PHP) And Intensive Outpatient Program (IOP) Reimbursement: Mental Health And Substance Use Disorder (SUD) Treatment
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 3 -- Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRFs) Reimbursement
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 4 -- Psychiatric Residential Treatment Center (RTC) Reimbursement
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 5 -- Opioid Treatment Programs (OTPs) Reimbursement
Change 83 (August 20, 2024)
Change 10 (November 15, 2017)
Baseline (April 1, 2015)
Addendum A -- Table Of Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume - Fiscal Year (FY) 2022 - FY 2024
Change 83 (August 20, 2024)
Change 66 (January 6, 2023)
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 37 (June 18, 2019)
Change 32 (February 8, 2019)
Change 16 (March 7, 2018)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Addendum B -- Guidelines For The Calculation Of Individual Psychiatric Residential Treatment Center (RTC) Per Diem Rates
Change 83 (August 20, 2024)
Change 66 (January 6, 2023)
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 37 (June 18, 2019)
Change 32 (February 8, 2019)
Change 25 (August 15, 2018)
Change 10 (November 15, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 8 -- Skilled Nursing Facilities (SNFs)
Change 44 (December 13, 2019)
Change 30 (January 15, 2019)
Change 13 (January 30, 2018)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Services Received Prior To October 1, 2019
Change 66 (January 6, 2023)
Change 44 (December 13, 2019)
Change 41 (September 20, 2019)
Change 21 (May 30, 2018)
Change 19 (May 18, 2018)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Sect 2 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Care Rendered On Or After October 1, 2019
Change 70 (June 12, 2023)
Change 50 (October 16, 2020)
Change 49 (June 9, 2020)
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum A -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Received On Or After October 1, 2019
Change 45 (March 13, 2020)
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum B -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum C -- Resource Utilization Group-III /IV (RUG-III/IV) Resource Utilization Group-III/IV (RUG-III/IV) For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum D -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2018 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Change 23 (July 3, 2018)
Change 13 (January 30, 2018)
Baseline (April 1, 2015)
Addendum D -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2019 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Change 37 (June 18, 2019)
Change 30 (January 15, 2019)
Baseline (April 1, 2015)
Addendum E -- Fact Sheet Regarding Consolidated Billing and Ambulance Services For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum F -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2018 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Change 13 (January 30, 2018)
Baseline (April 1, 2015)
Addendum F -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2019 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Change 30 (January 15, 2019)
Baseline (April 1, 2015)
Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2018 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2019 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2018 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2019 For Services Received Prior To October 1, 2019
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Chap 9 -- Ambulatory Surgery Centers (ASCs)
Baseline (April 1, 2015)
Sect 1 -- Ambulatory Surgical Center (ASC) Reimbursement For Services Before October 1, 2023
Change 76 (January 9, 2024)
Change 71 (August 1, 2023)
Change 66 (January 6, 2023)
Change 58 (April 20, 2021)
Change 45 (March 13, 2020)
Change 37 (June 18, 2019)
Change 25 (August 15, 2018)
Change 21 (May 30, 2018)
Change 14 (February 6, 2018)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 2 -- Ambulatory Surgical Center (ASC) Reimbursement For Service Dates To October 1, 2023
Change 77 (March 25, 2024)
Change 75 (November 17, 2023)
Change 71 (August 1, 2023)
Baseline (April 1, 2015)
Chap 10 -- Birthing Centers
Change 32 (February 8, 2019)
Change 4 (August 2, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Freestanding And Hospital-Based Birthing Center Reimbursement
Change 32 (February 8, 2019)
Change 15 (February 21, 2018)
Baseline (April 1, 2015)
Addendum A -- Birthing Center Rate Non-Professional Component
Change 32 (February 8, 2019)
Change 15 (February 21, 2018)
Change 4 (August 2, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 11 -- Hospice
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 39 (August 6, 2019)
Change 32 (February 8, 2019)
Change 16 (March 7, 2018)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Hospice Reimbursement - General Overview
Change 39 (August 6, 2019)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Change 62 (September 3, 2021)
Baseline (April 1, 2015)
Sect 3 -- Hospice Reimbursement - Conditions For Coverage
Change 39 (August 6, 2019)
Change 26 (September 14, 2018)
Change 16 (March 7, 2018)
Baseline (April 1, 2015)
Sect 4 -- Hospice Reimbursement - Guidelines For Payment Of Designated Levels Of Care
Change 75 (November 17, 2023)
Change 66 (January 6, 2023)
Change 51 (December 18, 2020)
Change 44 (December 13, 2019)
Change 41 (September 20, 2019)
Change 39 (August 6, 2019)
Change 32 (February 8, 2019)
Change 26 (September 14, 2018)
Change 19 (May 18, 2018)
Change 16 (March 7, 2018)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 5 -- Hospice Reimbursement - Concurrent Hospice Services And Curative Care For Pediatric Beneficiaries
Change 39 (August 6, 2019)
Baseline (April 1, 2015)
Addendum A -- Hospice Care Rates - FY 2022
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Addendum A -- Hospice Care Rates - FY 2023
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum A -- Hospice Care Rates - FY 2024
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2022
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2023
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2024
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum C -- HospiceRate Information - Hospice Wage Indexes For Rural Areas - FY 2022
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas - FY 2023
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas - FY 2024
Change 75 (November 17, 2023)
Baseline (April 1, 2015)
Addendum D -- Participation Agreement For Hospice Program Services For TRICARE Beneficiaries
Baseline (April 1, 2015)
Chap 12 -- Home Health Care (HHC)
Change 58 (April 20, 2021)
Change 46 (March 26, 2020)
Change 37 (June 18, 2019)
Change 24 (August 9, 2018)
Change 6 (October 20, 2017)
Change 3 (June 30, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 1 -- Home Health Benefit Coverage And Reimbursement - General Overview
Change 79 (June 4, 2024)
Change 67 (March 27, 2023)
Change 58 (April 20, 2021)
Change 46 (March 26, 2020)
Change 37 (June 18, 2019)
Change 31 (January 31, 2019)
Change 24 (August 9, 2018)
Change 6 (October 20, 2017)
Change 3 (June 30, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 2 -- Home Health Care (HHC) - Benefits And Conditions For Coverage
Change 46 (March 26, 2020)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 3 -- Home Health Benefit Coverage And Reimbursement - Assessment Process
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Sect 4 -- Home Health Benefit Coverage And Reimbursement - Prospective Payment Methodology
Change 79 (June 4, 2024)
Change 63 (December 23, 2021)
Change 58 (April 20, 2021)
Change 46 (March 26, 2020)
Change 37 (June 18, 2019)
Change 24 (August 9, 2018)
Change 21 (May 30, 2018)
Change 6 (October 20, 2017)
Change 3 (June 30, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 5 -- Home Health Benefit Coverage And Reimbursement - Primary Provider Status And Episodes Of Care (EOCs)
Change 46 (March 26, 2020)
Change 31 (January 31, 2019)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Sect 6 -- Home Health Benefit Coverage And Reimbursement - Claims And Billing Submission Under Home Health Agency Prospective Payment System (HHA PPS)
Change 66 (January 6, 2023)
Change 58 (April 20, 2021)
Change 46 (March 26, 2020)
Change 37 (June 18, 2019)
Change 31 (January 31, 2019)
Change 8 (October 27, 2017)
Change 3 (June 30, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 7 -- Home Health Benefit Coverage And Reimbursement - Pricer Requirements And Logic
Change 46 (March 26, 2020)
Change 37 (June 18, 2019)
Change 24 (August 9, 2018)
Change 3 (June 30, 2017)
Baseline (April 1, 2015)
Sect 8 -- Home Health Benefit Coverage And Reimbursement - Medical Review Requirements
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Sect 9 -- Home Health Benefit Coverage And Reimbursement - Under The Patient-Driven Groupings Model (PDGM)
Change 66 (January 6, 2023)
Change 58 (April 20, 2021)
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Addendum A -- Definitions And Acronym Table
Change 31 (January 31, 2019)
Change 21 (May 30, 2018)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Addendum B -- Home Health Resource Group (HHRG) Worksheet
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2022
Change 66 (January 6, 2023)
Baseline (April 1, 2015)
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2023
Change 67 (March 27, 2023)
Baseline (April 1, 2015)
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2024
Change 79 (June 4, 2024)
Baseline (April 1, 2015)
Addendum D -- Home Health Certification And Plan Of Care (POC)
Baseline (April 1, 2015)
Addendum E -- Code Table For Converting Julian Dates To Two Position Alphabetic Values
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Chap 13 -- Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
Baseline (April 1, 2015)
Sect 1 -- General
Change 71 (August 1, 2023)
Change 41 (September 20, 2019)
Change 21 (May 30, 2018)
Change 10 (November 15, 2017)
Change 6 (October 20, 2017)
Change 5 (August 23, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 2 -- Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
Change 21 (May 30, 2018)
Change 10 (November 15, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 3 -- Prospective Payment Methodology
Change 83 (August 20, 2024)
Change 77 (March 25, 2024)
Change 71 (August 1, 2023)
Change 21 (May 30, 2018)
Change 6 (October 20, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 4 -- Claims Submission And Processing Requirements
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Sect 5 -- Medical Review And Allowable Charge Review Under the Outpatient Prospective Payment System (OPPS)
Baseline (April 1, 2015)
Addendum A -- Development Schedule For TRICARE Outpatient Code Editor (OCE)/Ambulatory Payment Classification (APC) Quarterly Update
Baseline (April 1, 2015)
Addendum B -- Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Notification Process For Quarterly Updates
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Addendum C -- Approval Of OPPS - Outpatient Code Editor (OCE)/APC And No Government Pay List (NGPL) Quarterly Update Process
Baseline (April 1, 2015)
Chap 14 -- Sole Community Hospitals (SCHs)
Baseline (April 1, 2015)
Sect 1 -- Sole Community Hospitals (SCHs)
Change 44 (December 13, 2019)
Change 37 (June 18, 2019)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Chap 15 -- Critical Access Hospitals (CAHs)
Baseline (April 1, 2015)
Sect 1 -- Critical Access Hospitals (CAHs)
Change 62 (September 3, 2021)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Chap 16 -- Long-Term Care Hospitals (LTCHs)
Change 20 (May 24, 2018)
Baseline (April 1, 2015)
Sect 1 -- Long-Term Care Hospitals (LTCHs)
Change 41 (September 20, 2019)
Change 28 (November 6, 2018)
Change 20 (May 24, 2018)
Baseline (April 1, 2015)
Chap 17 -- Inpatient Rehabilitation Facilities (IRFs)
Change 20 (May 24, 2018)
Baseline (April 1, 2015)
Sect 1 -- Inpatient Rehabilitation Facilities (IRFs)
Change 41 (September 20, 2019)
Change 33 (February 20, 2019)
Change 28 (November 6, 2018)
Change 20 (May 24, 2018)
Baseline (April 1, 2015)
Chap 18 -- Freestanding End Stage Renal Disease (ESRD) Reimbursement
Baseline (April 1, 2015)
Sect 1 -- Freestanding End Stage Renal Disease (ESRD) Facility Reimbursement
Change 84 (October 16, 2024)
Change 79 (June 4, 2024)
Change 69 (May 31, 2023)
Baseline (April 1, 2015)
Obsolete Files
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 3 (June 30, 2017)
Change 2 (May 17, 2017)
Change 1 (March 10, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 2 (May 17, 2017)
Baseline (April 1, 2015)
Change 3 (June 30, 2017)
Baseline (April 1, 2015)
Change 37 (June 18, 2019)
Change 24 (August 9, 2018)
Change 21 (May 30, 2018)
Change 3 (June 30, 2017)
Baseline (April 1, 2015)
Change 20 (May 24, 2018)
Change 6 (October 20, 2017)
Baseline (April 1, 2015)
Change 23 (July 3, 2018)
Change 13 (January 30, 2018)
Baseline (April 1, 2015)
Change 13 (January 30, 2018)
Baseline (April 1, 2015)
Change 16 (March 7, 2018)
Baseline (April 1, 2015)
Change 16 (March 7, 2018)
Baseline (April 1, 2015)
Change 16 (March 7, 2018)
Baseline (April 1, 2015)
Change 41 (September 20, 2019)
Change 19 (May 18, 2018)
Baseline (April 1, 2015)
Change 21 (May 30, 2018)
Baseline (April 1, 2015)
Change 21 (May 30, 2018)
Baseline (April 1, 2015)
Change 24 (August 9, 2018)
Baseline (April 1, 2015)
Change 30 (January 15, 2019)
Baseline (April 1, 2015)
Change 30 (January 15, 2019)
Baseline (April 1, 2015)
Change 31 (January 31, 2019)
Baseline (April 1, 2015)
Change 37 (June 18, 2019)
Change 32 (February 8, 2019)
Baseline (April 1, 2015)
Change 44 (December 13, 2019)
Change 32 (February 8, 2019)
Baseline (April 1, 2015)
Change 44 (December 13, 2019)
Change 32 (February 8, 2019)
Baseline (April 1, 2015)
Change 37 (June 18, 2019)
Baseline (April 1, 2015)
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Change 44 (December 13, 2019)
Baseline (April 1, 2015)
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Change 46 (March 26, 2020)
Baseline (April 1, 2015)
Change 51 (December 18, 2020)
Baseline (April 1, 2015)
Change 51 (December 18, 2020)
Baseline (April 1, 2015)
Change 51 (December 18, 2020)
Baseline (April 1, 2015)
Change 69 (May 31, 2023)
Change 64 (August 3, 2022)
Change 57 (April 9, 2021)
Baseline (April 1, 2015)
Change 79 (June 4, 2024)
Change 58 (April 20, 2021)
Baseline (April 1, 2015)
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