Diagnosis Related Groups (DRGs)
Chapter 6
Addendum A
Health Benefit
Program Agreement
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In
order to receive payment under the TRICARE, _____________________________________________ _________________________
___________ dba ____________________________________________ as
the provider of services agrees:
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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.
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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.
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DHA
agrees:
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To
pay hospital the full allowable amount less any applicable cost-share
and deductible amounts.
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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.
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This
agreement shall be effective until terminated by either party. The
effective date shall be the date the agreement is signed by DHA.
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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.
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For Provider Of
Services By:
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For Defense Health
Agency By:
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Name
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Name
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Title
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Title
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Date
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Date
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- END -