Providers
Chapter 11
Section 9.2
State Vaccine Programs (SVPs) As TRICARE-Authorized Providers
Issue Date:
Authority:
32 CFR 199.6(d)(5), National
Defense Authorization Act for Fiscal Year 2017 (NDAA FY 2017), Public
Law (PL) 114-328Revision: C-15,
November 30, 2017
1.0 ISSUE
Can
State Vaccine Programs or State Vaccine Program entities (SVPs)
be certified under TRICARE and reimbursed for supplied vaccines
used to immunize TRICARE beneficiaries?
2.0 Background
2.1 SVPs are state
entities that supply vaccines at no cost to immunization providers
who use these vaccines to immunize children who reside in the state.
SVPs do not administer individual immunizations. Rather, these entities
simply supply the vaccines used in immunizations.
2.2 In order for
an SVP to be reimbursed for supplied vaccines used to immunize TRICARE beneficiaries
the SVP must be certified as a TRICARE-authorized provider.
32 CFR 199.6(d) lists those providers considered
as “other providers” under the TRICARE program. Furthermore,
32 CFR 199.6(d)(5) allows TRICARE-authorized
provider status for any firm, supplier, or provider that is an authorized provider
under Medicare or is otherwise designated as authorized by the Director,
Defense Health Agency (DHA).
2.3 On May 20, 2014, a Decision Paper was signed
by the Director,
DHA to allow an SVP
to be certified as a TRICARE-authorized supplier of vaccines under
32 CFR 199.6(d)(5) when the SVP executes a
TRICARE Participation Agreement and agrees to comply with TRICARE
legal and program requirements.
These are known as
Dosage Based SVPs.
2.4 On
December 23, 2016, based on the authority provided in the NDAA FY
2017, Section 719, a Decision Paper was signed by the Director,
DHA to extend certification as a TRICARE-authorized supplier of
vaccines under 32 CFR 199.6(d)(5) to all other SVPs which
agree to be reimbursed on a per capita assessment without executing
a participation agreement. These are known as Per Capita Based SVPs.
3.0 Policy
3.1 A
Dosage
Based SVP may be certified as a TRICARE-authorized
provider under the “other” category of provider as a supplier of
vaccines when all of the following specific requirements are met:
3.1.1 The Dosage
Based SVP must hold a valid National Provider Identification
(NPI) number.
3.1.3 The SVP must
agree to accept the lesser of the TRICARE allowed amount or the
billed charge in accordance with
32 CFR 199.14 (i.e.,
the SVP-specific amount that is charged to other payers) as payment
in full for the vaccines supplied. The SVP must also agree to not
balance bill the beneficiary.
3.2 A Per Capita Based SVP may
be certified as a TRICARE-authorized provider under the “other” category
of provider as a supplier of vaccines.
3.3 Each
contractor is the certifying authority for SVPs located within their
geographical jurisdiction, to include obtaining the required participation
agreement.
3.4 This policy
applies to SVPs and SVP entities located within the continental
U.S. to include Alaska and Hawaii, the Commonwealth of Puerto Rico,
and all U.S. territories. Information regarding Per
Capita Based SVPs not apply to the TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC) or TRICARE Overseas Program (TOP).
4.0 Reimbursement
Of SVP
sSee
the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 38 for reimbursement of Dosage
Based SVPs and Per Capita Based SVPs.
5.0 Effective
Date
sAn SVP that
meets the requirements of this policy for Dosage Based
SVP may be certified as a TRICARE-authorized supplier
of vaccines on or after May 20, 2014. The effective date for certification
of a specific SVP, for the purposes of claims reimbursement, is
the date the required participation agreement is signed. An
SVP that meets the requirements of this policy for Per Capita Based
SVP may be certified on or after December 23, 2016.
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