3.1 Covered
services provided by all TRICARE authorized individual health care
providers and
other non-institutional health care providers
shall be
reimbursed using the allowable charge methodology unless otherwise
stated.
3.1.1 This
policy applies to all categories of individual health care providers and
professionals that would otherwise meet the qualifications of individual health
care providers except that they are either employed
by or under contract to an institutional provider, and other non-institutional
providers regardless of the beneficiary services
provided.
3.1.2 This policy applies to all locations,
inpatient or outpatient, where services are provided by these providers.
These services could be provided by individual health care
providers in
a Diagnosis Related Groups (DRG) hospital, a DRG exempt hospital,
an Ambulatory Surgery Center (ASC), or in a facility without a TRICARE
all-inclusive rate.
Note: Facility
charges for inpatient and outpatient services shall continue
to be billed on the current Centers
for Medicare and Medicaid Services (CMS) 1450 UB-04. This would
include inpatient services that are and have been included in the
reimbursement under the DRG-based payment system or the mental health
per diem payment system. Outpatient facility charges would include
services that aid the individual health care provider in the treatment
of the beneficiary. These charges may
include such services as the use of hospital facilities factoring
in overhead costs of utilities, billing, equipment and maintenance
costs, insurance, nursing staff, etc., including emergency room
services (nonprofessional services), the services of nurses, technicians,
and other aides, medical supplies (gauze, oxygen, ointments, dressings,
splints, casts, prosthetic devices), and drugs and biologicals which cannot
be self-administered.
3.1.3 Services provided by individual authorized
health care providers and other non-institutional
health care providers shall be billed
only on the current CMS 1500 Claim
Form or the TRICARE 2642 for payment. Individual health care providers (e.g.,
physicians) and non-institutional providers (e.g., suppliers) are
to use the CMS 1500 Claim Form. Institutional providers (e.g., hospitals) are
to use the CMS 1500 Claim Form or the CMS 1450 UB-04 (if adequate
Common Procedure Terminology (CPT) coding information is submitted)
to bill for the professional component of physicians and other authorized
professional providers. Beneficiaries (or their representatives)
who complete and file their own claims for individual health care providers and
other non-institutional health care provider services may want to
use the TRICARE 2642 claim form for payment.