Operational Requirements
Chapter 3
Section 7
No Government Pay Procedure
Codes
Issue Date:
Copyright: HCPCS
Level I/CPT only © 2006 American Medical Association (or such other
date of publication of CPT). All Rights Reserved.
Revision: C-37, June 18, 2019
1.0
ApplicabilityThis policy is mandatory for
reimbursement of services provided by either network or non-network
providers.
2.0 DescriptionThis policy provides information
on the TRICARE No Government Pay Procedure Code List (NGPL), and
clarifies that the NGPL is used as an editing tool only.
3.0 Policy3.1 The NGPL is an editing tool made
available to contractors and the public, which represents Current
Procedural Terminology (CPT) and Healthcare Common Procedure Coding
System (HCPCS) codes most likely to be denied coverage under the
TRICARE Basic Program, based on TRICARE statute, regulation and
policy. This list is not intended to provide a comprehensive list
of all denied items and services, and the information published
in the NGPL is subject to change.
3.2 The NGPL does not serve as TRICARE
policy. There are other policy or special program provisions (such
as rare diseases, demonstration projects, the Extended Care Health
Option (ECHO), etc.) that affect coverage and may override the NGPL.
Rather, the list shall be used in conjunction with the TRICARE Manuals,
which provide clarification and additional services, equipment and
supplies that are excluded from coverage under the TRICARE Basic
Program.
3.3 The
contractors shall not use the NGPL as a denial reason or issue any
denial on the basis that a code was on the NGPL, as Appeal rights
depend on the reason an item or service was denied.
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