TRICARE Manuals - Change History

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Manual Change History

TRICARE Reimbursement Manual 6010.64-M, April 2021
- Foreword
  - Baseline (December 5, 2022)
- Chapter 1 -- General
  - Baseline (December 5, 2022)
  - Sect 1 -- Network Provider Reimbursement
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  - Sect 2 -- Accommodation Of Discounts Under Provider Reimbursement Methods
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  - Sect 3 -- Claims Auditing Software
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  - Sect 4 -- Reimbursement In Teaching Setting
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  - Sect 5 -- National Health Service Corps (NHSC) Physicians Of The Public Health Service (PHS)
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  - Sect 6 -- Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)
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  - Sect 7 -- Reimbursement Of Covered Services Provided By Individual Health Care Providers And Other Non-Institutional Health Care Providers
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  - Sect 8 -- Economic Interest In Connection With Mental Health Admissions
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  - Sect 9 -- Anesthesia
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  - Sect 10 -- Postoperative Pain Management - Epidural Analgesia
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  - Sect 11 -- Claims For Durable Equipment (DE) And Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)
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  - Sect 12 -- Oxygen And Related Supplies
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  - Sect 13 -- Laboratory Services
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  - Sect 14 -- Ambulance Services
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  - Sect 15 -- Legend Drugs And Insulin
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  - Sect 16 -- Surgery
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  - Sect 17 -- Assistant Surgeons
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  - Sect 18 -- Professional Services: Obstetrical Care
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  - Sect 19 -- Charges For Provider Administrative Expenses
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  - Sect 20 -- State Agency Billing
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  - Sect 21 -- Hospital Reimbursement - Billed Charges Set Rates
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  - Sect 22 -- Hospital Reimbursement - Other Than Billed Charges
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  - Sect 23 -- Hospital Reimbursement - Payment When Only Skilled Nursing Facility (SNF) Level Of Care Is Required
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  - Sect 24 -- Hospital Reimbursement - Outpatient Services
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  - Sect 25 -- Preferred Provider Organization (PPO) Reimbursement
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  - Sect 26 -- Supplemental Insurance
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  - Sect 27 -- Legal Obligation To Pay
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  - Sect 28 -- Reduction Of Payment For Noncompliance With Utilization Review Requirements
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  - Sect 29 -- Reimbursement Of Emergency Inpatient Admissions To Unauthorized Facilities
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  - Sect 30 -- Reimbursement Of Travel Expenses For Specialty Care
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  - Sect 31 -- Newborn Charges
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  - Sect 32 -- Hospital-Based Birthing Room
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  - Sect 33 -- Bonus Payments In Health Professional Shortage Areas (HPSAs)
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  - Sect 34 -- Hospital Inpatient Reimbursement In Locations Outside The 50 United States (US) And The District Of Columbia
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  - Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States (US) And The District Of Columbia
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  - Sect 36 -- Forensic Examinations Following Sexual Assault or Domestic Violence
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  - Sect 37 -- Medical Errors
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  - Sect 38 -- Reimbursement of State Vaccine Programs (SVPs)
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  - Sect 39 -- CHAMPUS Maximum Allowable Charge (CMAC) For Banked Donor Milk (BDM)
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  - Sect 40 -- Organ Acquisition Costs
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  - Sect 41 -- Hospital Reimbursement - Hospital Value-Based Purchasing (HVBP)
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  - Sect 42 -- Temporary Reimbursement Changes In Response To The Coronavirus Disease 2019 (COVID-19) Pandemic
    - Baseline (December 5, 2022)
  - Addendum A -- Sample State Agency Billing Agreement
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  - Addendum B -- Figures
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  - Addendum C -- Minimum Requirements For Reimbursement Of Per Capita State (Or Alternative) State Vaccine Programs (SVPs)
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  - Addendum D -- Maximum Allowable Charge For Breastfeeding Supplies
    - Baseline (December 5, 2022)
- Chapter 2 -- Beneficiary Liability
  - Baseline (December 5, 2022)
  - 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
    - Baseline (December 5, 2022)
  - Sect 2 -- Cost-Shares And Deductibles For TRICARE Services Received On Or After January 1, 2018
    - Baseline (December 5, 2022)
  - 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
    - Baseline (December 5, 2022)
  - Sect 4 -- Catastrophic Loss Protection For TRICARE Services Received On Or After January 1, 2018
    - Baseline (December 5, 2022)
  - Sect 5 -- Point Of Service (POS) Option
    - Baseline (December 5, 2022)
  - Sect 6 -- Waivers of Cost-Shares and Deductibles
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  - Sect 7 -- Temporary Waivers of Copayments and Cost-Shares (Including Deductibles) in Response to Coronavirus 2019 (COVID-19) Pandemic
    - Baseline (December 5, 2022)
  - 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
    - Baseline (December 5, 2022)
  - Addendum B -- Pharmacy Benefits Program - Cost-Shares
    - Baseline (December 5, 2022)
- Chapter 3 -- Operational Requirements
  - Baseline (December 5, 2022)
  - Sect 1 -- Reimbursement Of Individual Health Care Professionals And Other Non-Institutional Health Care Providers
    - Baseline (December 5, 2022)
  - Sect 2 -- Hospital And Other Institutional Reimbursement
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  - Sect 3 -- Discounts
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  - Sect 4 -- Payment Reduction
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  - Sect 5 -- Reimbursement Administration
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  - Sect 6 -- Processing And Payment Of Home Infusion Claims
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  - Sect 7 -- No Government Pay Procedure Codes
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- Chapter 4 -- Double Coverage
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  - Sect 1 -- Double Coverage
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  - Sect 2 -- Double Coverage Review And Processing Of Claims
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  - Sect 3 -- Coordination Of Benefits (COB)
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  - Sect 4 -- Specific Double Coverage Actions
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- Chapter 5 -- Allowable Charges
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  - Sect 1 -- Providers
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  - Sect 2 -- Locality-Based Reimbursement Rate Waiver
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  - Sect 3 -- CHAMPUS Maximum Allowable Charges (CMAC)
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  - Sect 4 -- Payment For Professional/Technical Components Of Diagnostic Services
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- Chapter 6 -- Diagnosis Related Groups (DRGs)
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  - Sect 1 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General)
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  - Sect 2 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General Description Of System)
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  - Sect 3 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Basis Of Payment)
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  - Sect 4 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Applicability Of The DRG System)
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  - Sect 5 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Determination Of Payment Amounts)
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  - Sect 6 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (DRG Weighting Factors)
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  - Sect 7 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjusted Standardized Amounts (ASAs))
    - Baseline (December 5, 2022)
  - Sect 8 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts)
    - Baseline (December 5, 2022)
  - Sect 9 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Information Provided By Defense Health Agency (DHA))
    - Baseline (December 5, 2022)
  - Sect 10 -- Chap 6 Sect 10 --Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Charges To Beneficiaries)
    - Baseline (December 5, 2022)
  - Sect 11 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (New Technology Add-On Payments (NTAPs))
    - Baseline (December 5, 2022)
  - Addendum A -- Health Benefit Program Agreement
    - Baseline (December 5, 2022)
  - Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2015
    - Baseline (December 5, 2022)
  - Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - Fiscal Year (FY) 2016 And Beyond
    - Baseline (December 5, 2022)
  - 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 (December 5, 2022)
  - 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
    - Baseline (December 5, 2022)
- Chapter 7 -- Mental Health
  - Baseline (December 5, 2022)
  - Sect 1 -- Hospital Reimbursement - TRICARE Inpatient Mental Health Per Diem Payment System
    - Baseline (December 5, 2022)
  - Sect 2 -- Partial Hospitalization Program (PHP) And Intensive Outpatient Program (IOP) Reimbursement: Mental Health And Substance Use Disorder (SUD) Treatment
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  - Sect 3 -- Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRFs) Reimbursement
    - Baseline (December 5, 2022)
  - Sect 4 -- Psychiatric Residential Treatment Center (RTC) Reimbursement
    - Baseline (December 5, 2022)
  - Sect 5 -- Opioid Treatment Programs (OTPs) Reimbursement
    - Baseline (December 5, 2022)
  - Addendum A -- Table Of Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume - FY 2019 - FY 2021
    - Baseline (December 5, 2022)
  - Addendum B -- Guidelines For The Calculation Of Individual Psychiatric Residential Treatment Center (RTC) Per Diem Rates
    - Baseline (December 5, 2022)
- Chapter 8 -- Skilled Nursing Facilities (SNFs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Services Received Prior To October 1, 2019
    - Baseline (December 5, 2022)
  - Sect 2 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Care Rendered On Or After October 1, 2019
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  - Addendum A -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Received On Or After October 1, 2019
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  - Addendum B -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Prior To October 1, 2019
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  - Addendum C -- Resource Utilization Group-III/IV (RUG-III/IV) For Services Received Prior To October 1, 2019
    - Baseline (December 5, 2022)
  - 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
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  - Addendum E -- Fact Sheet Regarding Consolidated Billing and Ambulance Services For Services Received Prior To October 1, 2019
    - Baseline (December 5, 2022)
  - Addendum F -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs)
    - Baseline (December 5, 2022)
  - Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas
    - Baseline (December 5, 2022)
  - Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas
    - Baseline (December 5, 2022)
- Chapter 9 -- Ambulatory Surgery Centers (ASCs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Chap 9 Sect 1 -- Ambulatory Surgical Center (ASC) Reimbursement
    - Baseline (December 5, 2022)
- Chapter 10 -- Birthing Centers
  - Baseline (December 5, 2022)
  - Sect 1 -- Freestanding And Hospital-Based Birthing Center Reimbursement
    - Baseline (December 5, 2022)
  - Addendum A -- Birthing Center Rate Non-Professional Component
    - Baseline (December 5, 2022)
- Chapter 11 -- Hospice
  - Baseline (December 5, 2022)
  - Sect 1 -- Hospice Reimbursement - General Overview
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  - Sect 2 -- Hospice Reimbursement - Coverage/Benefits
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  - Sect 3 -- Hospice Reimbursement - Conditions For Coverage
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  - Sect 2 -- Hospice Reimbursement - Coverage/Benefits
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  - Sect 2 -- Hospice Reimbursement - Coverage/Benefits
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  - Addendum A -- Hospice Care Rates - FY 2019
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  - Addendum A -- Hospice Care Rates - FY 2020
    - Baseline (December 5, 2022)
  - Addendum A -- Hospice Care Rates - FY 2021
    - Baseline (December 5, 2022)
  - Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas
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  - Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas
    - Baseline (December 5, 2022)
  - Addendum D -- Participation Agreement For Hospice Program Services For TRICARE Beneficiaries
    - Baseline (December 5, 2022)
- Chapter 12 -- Home Health Care (HHC)
  - Baseline (December 5, 2022)
  - Sect 1 -- Home Health Benefit Coverage And Reimbursement - General Overview
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  - Sect 2 -- Home Health Care (HHC) - Benefits And Conditions For Coverage
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  - Sect 3 -- Home Health Benefit Coverage And Reimbursement - Assessment Process
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  - Sect 4 -- Home Health Benefit Coverage And Reimbursement - Primary Provider Status And Episodes/Periods Of Care
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  - Sect 5 -- Home Health Benefit Coverage And Reimbursement - Medical Review Requirements
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  - Sect 6 -- Home Health Benefit Coverage And Reimbursement - Under The Patient-Driven Groupings Model (PDGM)
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  - Addendum A -- Definitions And Acronym Table
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  - Addendum B -- Home Health Resource Group (HHRG) Worksheet
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  - Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2019
    - Baseline (December 5, 2022)
  - Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2020
    - Baseline (December 5, 2022)
  - Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2021
    - Baseline (December 5, 2022)
  - Addendum D -- Home Health Certification And Plan Of Care (POC)
    - Baseline (December 5, 2022)
  - Addendum E -- Code Table For Converting Julian Dates To Two Position Alphabetic Values
    - Baseline (December 5, 2022)
- Chapter 13 -- Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
  - Baseline (December 5, 2022)
  - Sect 1 -- Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
    - Baseline (December 5, 2022)
  - Sect 2 -- Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
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  - Sect 3 -- Prospective Payment Methodology
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  - Sect 4 -- Claims Submission And Processing Requirements
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  - Sect 5 -- Medical Review And Allowable Charge Review Under the Outpatient Prospective Payment System (OPPS)
    - Baseline (December 5, 2022)
  - Addendum A -- Development Schedule For TRICARE Outpatient Code Editor (OCE)/Ambulatory Payment Classification (APC) Quarterly Update
    - Baseline (December 5, 2022)
  - Addendum B -- Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Notification Process For Quarterly Updates
    - Baseline (December 5, 2022)
  - Addendum C -- Approval Of OPPS - Outpatient Code Editor (OCE)/APC And No Government Pay List (NGPL) Quarterly Update Process
    - Baseline (December 5, 2022)
- Chapter 14 -- Sole Community Hospitals (SCHs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Sole Community Hospitals (SCHs)
    - Baseline (December 5, 2022)
- Chapter 15 -- Critical Access Hospitals (CAHs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Critical Access Hospitals (CAHs)
    - Baseline (December 5, 2022)
- Chapter 16 -- Long-Term Care Hospitals (LTCHs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Long-Term Care Hospitals (LTCHs)
    - Baseline (December 5, 2022)
- Chapter 17 -- Inpatient Rehabilitation Facilities (IRFs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Inpatient Rehabilitation Facilities (IRFs)
    - Baseline (December 5, 2022)
- Chapter 18 -- Alternate Payment Models (APMs)
  - Baseline (December 5, 2022)
  - Sect 1 -- Alternate Payment Models (APMs)
    - Baseline (December 5, 2022)
  - Sect 2 -- Low-Value Care (LVC) Medical Interventions
    - Baseline (December 5, 2022)
- Obsolete Files

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