Back to Top Skip to main content the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Diagnosis Related Groups (DRGs)
Chapter 6
Addendum A
Health Benefit Program Agreement
In order to receive payment under the TRICARE, _____________________________________________ _________________________ ___________ dba ____________________________________________ as the provider of services agrees:
To accept as payment for inpatient services provided to eligible beneficiaries, the allowable amount under TRICARE will be determined in accordance with the requirements of 32 CFR 199.
To refrain from billing the TRICARE-eligible beneficiary for amounts which exceed the allowable amount under TRICARE except for services not covered by TRICARE as described in 32 CFR 199 and for amounts which constitute the TRICARE beneficiary’s liability for cost-share and deductible.
DHA agrees:
To pay hospital the full allowable amount less any applicable cost-share and deductible amounts.
This agreement shall be binding on the provider and DHA upon submission by the provider of acceptable assurance of compliance with Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by the Deputy Director, DHA, or his designee.
This agreement shall be effective until terminated by either party. The effective date shall be the date the agreement is signed by DHA.
The agreement may be terminated by either party by giving the other party written notice of termination. Such notice of termination is to be received by the other party no later than 30 days prior to the date of termination. In the event of transfer of ownership, this agreement is assigned to the new owner, subject to the conditions specified in this agreement and pertinent regulations.
For Provider Of Services By:
For Defense Health Agency By:
- END -

Utility Navigation Links

DoD Seal is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Help page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.


DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.