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.