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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 6010.64-M, April 2021
Manual Change History
TRICARE Reimbursement Manual 6010.64-M, April 2021
Foreword
Baseline (December 5, 2022)
Chap 1 -- General
Baseline (December 5, 2022)
Sect 1 -- Network Provider Reimbursement
Baseline (December 5, 2022)
Sect 2 -- Accommodation Of Discounts Under Provider Reimbursement Methods
Baseline (December 5, 2022)
Sect 3 -- Claims Auditing Software
Baseline (December 5, 2022)
Sect 4 -- Reimbursement In Teaching Setting
Baseline (December 5, 2022)
Sect 5 -- National Health Service Corps (NHSC) Physicians Of The Public Health Service (PHS)
Baseline (December 5, 2022)
Sect 6 -- Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)
Baseline (December 5, 2022)
Sect 7 -- Reimbursement Of Covered Services Provided By Individual Health Care Providers And Other Non-Institutional Health Care Providers
Baseline (December 5, 2022)
Sect 8 -- Economic Interest In Connection With Mental Health Admissions
Baseline (December 5, 2022)
Sect 9 -- Anesthesia
Baseline (December 5, 2022)
Sect 10 -- Postoperative Pain Management - Epidural Analgesia
Baseline (December 5, 2022)
Sect 11 -- Claims For Durable Equipment (DE) And Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)
Change 2 (April 23, 2024)
Baseline (December 5, 2022)
Sect 12 -- Oxygen And Related Supplies
Baseline (December 5, 2022)
Sect 13 -- Laboratory Services
Baseline (December 5, 2022)
Sect 14 -- Ambulance Services
Baseline (December 5, 2022)
Sect 15 -- Legend Drugs And Insulin
Baseline (December 5, 2022)
Sect 16 -- Surgery
Baseline (December 5, 2022)
Sect 17 -- Assistant Surgeons
Baseline (December 5, 2022)
Sect 18 -- Professional Services: Obstetrical Care
Baseline (December 5, 2022)
Sect 19 -- Charges For Provider Administrative Expenses
Baseline (December 5, 2022)
Sect 20 -- State Agency Billing
Baseline (December 5, 2022)
Sect 21 -- Hospital Reimbursement - Billed Charges Set Rates
Baseline (December 5, 2022)
Sect 22 -- Hospital Reimbursement - Other Than Billed Charges
Baseline (December 5, 2022)
Sect 23 -- Hospital Reimbursement - Payment When Only Skilled Nursing Facility (SNF) Level Of Care Is Required
Baseline (December 5, 2022)
Sect 24 -- Hospital Reimbursement - Outpatient Services
Baseline (December 5, 2022)
Sect 25 -- Preferred Provider Organization (PPO) Reimbursement
Baseline (December 5, 2022)
Sect 26 -- Supplemental Insurance
Baseline (December 5, 2022)
Sect 27 -- Legal Obligation To Pay
Baseline (December 5, 2022)
Sect 28 -- Reduction Of Payment For Noncompliance With Utilization Review Requirements
Baseline (December 5, 2022)
Sect 29 -- Reimbursement Of Emergency Inpatient Admissions To Unauthorized Facilities
Baseline (December 5, 2022)
Sect 30 -- Reimbursement Of Travel Expenses For Specialty Care
Change 1 (April 16, 2024)
Baseline (December 5, 2022)
Sect 31 -- Newborn Charges
Baseline (December 5, 2022)
Sect 32 -- Hospital-Based Birthing Room
Baseline (December 5, 2022)
Sect 33 -- Bonus Payments In Health Professional Shortage Areas (HPSAs)
Baseline (December 5, 2022)
Sect 34 -- Hospital Inpatient Reimbursement In Locations Outside The 50 United States (US) And The District Of Columbia
Change 6 (August 7, 2024)
Baseline (December 5, 2022)
Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States (US) And The District Of Columbia
Change 6 (August 7, 2024)
Baseline (December 5, 2022)
Sect 36 -- Forensic Examinations Following Sexual Assault or Domestic Violence
Baseline (December 5, 2022)
Sect 37 -- Medical Errors
Baseline (December 5, 2022)
Sect 38 -- Reimbursement of State Vaccine Programs (SVPs)
Baseline (December 5, 2022)
Sect 39 -- CHAMPUS Maximum Allowable Charge (CMAC) For Banked Donor Milk (BDM)
Baseline (December 5, 2022)
Sect 40 -- Organ Acquisition Costs
Baseline (December 5, 2022)
Sect 41 -- Hospital Reimbursement - Hospital Value-Based Purchasing (HVBP)
Baseline (December 5, 2022)
Sect 42 -- Temporary Reimbursement Changes In Response To The Coronavirus Disease 2019 (COVID-19) Pandemic
Change 4 (June 20, 2024)
Change 3 (June 13, 2024)
Baseline (December 5, 2022)
Addendum A -- Sample State Agency Billing Agreement
Baseline (December 5, 2022)
Addendum B -- Figures
Baseline (December 5, 2022)
Addendum C -- Minimum Requirements For Reimbursement Of Per Capita State (Or Alternative) State Vaccine Programs (SVPs)
Baseline (December 5, 2022)
Addendum D -- Maximum Allowable Charge For Breastfeeding Supplies
Change 2 (April 23, 2024)
Baseline (December 5, 2022)
Addendum E -- Controls for Excessive Charges for Professional Services, and Durable Medical Equipment, Prosthetics, Orthotics, And Supplies/Parenteral and Enteral Nutrition (DMEPOS/PEN) Services without Established Rates
Change 8 (August 23, 2024)
Baseline (December 5, 2022)
Chap 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
Change 5 (July 24, 2024)
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
Change 5 (July 24, 2024)
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
Baseline (December 5, 2022)
Sect 7 -- Temporary Waivers of Copayments and Cost-Shares (Including Deductibles) in Response to Coronavirus 2019 (COVID-19) Pandemic
Change 3 (June 13, 2024)
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)
Chap 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
Baseline (December 5, 2022)
Sect 3 -- Discounts
Baseline (December 5, 2022)
Sect 4 -- Payment Reduction
Baseline (December 5, 2022)
Sect 5 -- Reimbursement Administration
Baseline (December 5, 2022)
Sect 6 -- Processing And Payment Of Home Infusion Claims
Baseline (December 5, 2022)
Sect 7 -- No Government Pay Procedure Codes
Baseline (December 5, 2022)
Chap 4 -- Double Coverage
Baseline (December 5, 2022)
Sect 1 -- Double Coverage
Baseline (December 5, 2022)
Sect 2 -- Double Coverage Review And Processing Of Claims
Baseline (December 5, 2022)
Sect 3 -- Coordination Of Benefits (COB)
Baseline (December 5, 2022)
Sect 4 -- Specific Double Coverage Actions
Baseline (December 5, 2022)
Chap 5 -- Allowable Charges
Baseline (December 5, 2022)
Sect 1 -- Providers
Baseline (December 5, 2022)
Sect 2 -- Locality-Based Reimbursement Rate Waiver
Baseline (December 5, 2022)
Sect 3 -- CHAMPUS Maximum Allowable Charges (CMAC)
Baseline (December 5, 2022)
Sect 4 -- Payment For Professional/Technical Components Of Diagnostic Services
Baseline (December 5, 2022)
Chap 6 -- Diagnosis Related Groups (DRGs)
Baseline (December 5, 2022)
Sect 1 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General)
Baseline (December 5, 2022)
Sect 2 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General Description Of System)
Baseline (December 5, 2022)
Sect 3 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Basis Of Payment)
Baseline (December 5, 2022)
Sect 4 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Applicability Of The DRG System)
Baseline (December 5, 2022)
Sect 5 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Determination Of Payment Amounts)
Baseline (December 5, 2022)
Sect 6 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (DRG Weighting Factors)
Baseline (December 5, 2022)
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)
Chap 7 -- Mental Health
Baseline (December 5, 2022)
Sect 1 -- Hospital Reimbursement - TRICARE Inpatient Mental Health Per Diem Payment System
Change 7 (August 21, 2024)
Baseline (December 5, 2022)
Sect 2 -- Partial Hospitalization Program (PHP) And Intensive Outpatient Program (IOP) Reimbursement: Mental Health And Substance Use Disorder (SUD) Treatment
Baseline (December 5, 2022)
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
Change 7 (August 21, 2024)
Baseline (December 5, 2022)
Addendum A -- Table Of Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume - FY 2022 - FY 2024
Change 7 (August 21, 2024)
Baseline (December 5, 2022)
Addendum B -- Guidelines For The Calculation Of Individual Psychiatric Residential Treatment Center (RTC) Per Diem Rates
Change 7 (August 21, 2024)
Baseline (December 5, 2022)
Chap 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
Baseline (December 5, 2022)
Addendum A -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Received On Or After October 1, 2019
Baseline (December 5, 2022)
Addendum B -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Prior To October 1, 2019
Baseline (December 5, 2022)
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
Baseline (December 5, 2022)
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)
Chap 9 -- Ambulatory Surgery Centers (ASCs)
Baseline (December 5, 2022)
Sect 1 -- Chap 9 Sect 1 -- Ambulatory Surgical Center (ASC) Reimbursement
Baseline (December 5, 2022)
Chap 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)
Chap 11 -- Hospice
Baseline (December 5, 2022)
Sect 1 -- Hospice Reimbursement - General Overview
Baseline (December 5, 2022)
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Change 5 (July 24, 2024)
Baseline (December 5, 2022)
Sect 3 -- Hospice Reimbursement - Conditions For Coverage
Baseline (December 5, 2022)
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Baseline (December 5, 2022)
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Baseline (December 5, 2022)
Addendum A -- Hospice Care Rates - FY 2019
Baseline (December 5, 2022)
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
Baseline (December 5, 2022)
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)
Chap 12 -- Home Health Care (HHC)
Baseline (December 5, 2022)
Sect 1 -- Home Health Benefit Coverage And Reimbursement - General Overview
Baseline (December 5, 2022)
Sect 2 -- Home Health Care (HHC) - Benefits And Conditions For Coverage
Baseline (December 5, 2022)
Sect 3 -- Home Health Benefit Coverage And Reimbursement - Assessment Process
Baseline (December 5, 2022)
Sect 4 -- Home Health Benefit Coverage And Reimbursement - Primary Provider Status And Episodes/Periods Of Care
Baseline (December 5, 2022)
Sect 5 -- Home Health Benefit Coverage And Reimbursement - Medical Review Requirements
Baseline (December 5, 2022)
Sect 6 -- Home Health Benefit Coverage And Reimbursement - Under The Patient-Driven Groupings Model (PDGM)
Baseline (December 5, 2022)
Addendum A -- Definitions And Acronym Table
Baseline (December 5, 2022)
Addendum B -- Home Health Resource Group (HHRG) Worksheet
Baseline (December 5, 2022)
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)
Chap 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
Baseline (December 5, 2022)
Sect 3 -- Prospective Payment Methodology
Baseline (December 5, 2022)
Sect 4 -- Claims Submission And Processing Requirements
Baseline (December 5, 2022)
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)
Chap 14 -- Sole Community Hospitals (SCHs)
Baseline (December 5, 2022)
Sect 1 -- Sole Community Hospitals (SCHs)
Baseline (December 5, 2022)
Chap 15 -- Critical Access Hospitals (CAHs)
Baseline (December 5, 2022)
Sect 1 -- Critical Access Hospitals (CAHs)
Change 5 (July 24, 2024)
Baseline (December 5, 2022)
Chap 16 -- Long-Term Care Hospitals (LTCHs)
Baseline (December 5, 2022)
Sect 1 -- Long-Term Care Hospitals (LTCHs)
Baseline (December 5, 2022)
Chap 17 -- Inpatient Rehabilitation Facilities (IRFs)
Baseline (December 5, 2022)
Sect 1 -- Inpatient Rehabilitation Facilities (IRFs)
Baseline (December 5, 2022)
Chap 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)
Chap 19 -- Freestanding End Stage Renal Disease (ESRD) Facility Reimbursement
Baseline (December 5, 2022)
Sect 1 -- Freestanding End Stage Renal Disease (ESRD) Facility Reimbursement
Change 4 (June 20, 2024)
Baseline (December 5, 2022)
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