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 -