3.1 Background
3.1.1 On April
15, 2002, the Final Rule was published in the Federal Register (67
FR 18114), allowing for bonus payments, in addition to the amount
normally paid under the allowable charge methodology, to providers
in medically underserved areas. Medically underserved areas are
the same as those determined by the Secretary of Health and Human
Services (HHS) for the Medicare program, designated as HPSAs found
in all 50 states and Puerto Rico. HPSAs include both primary care
and mental health identified HPSAs.
3.1.2 The bonus payments shall be
equal to the bonus payments authorized by Medicare, except as necessary
to recognize any unique or distinct characteristics or requirements
of the TRICARE program, and as described in instructions issued
by the Deputy Director, DHA.
3.1.3 HPSAs include both primary
care and mental health identified HPSAs.
3.1.4 The bonus payment applies
to both assigned and non-assigned claims. It also applies to network
and non-network physicians.
3.1.5 The
bonus payment is based on the zip code of the location where the
service is actually performed, which must be in an HPSA, rather
than the zip code of the billing office or other location.
3.1.6 The
bonus payment is based solely on the amount paid for professional
services. Professional services are those that are paid by the professional
CHAMPUS Maximum Allowable Charge (CMAC) file, excluding codes that
are clinical laboratory services or that are entirely technical
in nature. Claims submitted for the technical component only of
a service (i.e., have a -TC modifier), if a service can
have both professional and technical components, are also ineligible
for the HPSA bonus. Thus, all Durable Equipment (DE), injectable
drugs, vaccines, facility charges, supplies, etc., are not included
in the paid amounts used to calculate the HPSA bonus. The professional
service CMAC file’s documentation describes how codes can be detected
which are considered entirely technical or clinical lab. Anesthesia
services by physicians paid through the anesthesia Relative Value
Unit (RVU) and Conversion Factor (CF) files are also to be included
as eligible services for the HPSA bonus calculation. Services that
are performed by physicians and are professional services (not supplies, drugs,
or other such charges) but do not have CMACs may be included in
the HPSA bonus calculation, also, such as unlisted or “not elsewhere
specified” CPT codes 27599, 27899, 30999, etc.
3.1.7 For
dates of service prior to January 1, 2018, bonus
payments apply under TRICARE Prime, Extra,
and Standard for services provided in medically underserved areas. For
dates of service on or after January 1, 2018, bonus payments apply
under TRICARE Prime and Select for services provided in medically
underserved areas.
3.1.8 TRICARE Prime Remote (TPR)
and Supplemental Health Care Program (SHCP) shall be included in
the bonus payment process.
3.1.9 Under TRICARE For Life (TFL),
only those claims where TRICARE is primary would qualify for the
bonus payment.
3.1.10 For Other
Health Insurance (OHI) claims, the bonus payment would apply, but
only on the amount paid by the Government.