2.2 Network provider reimbursement
is neither subject to, nor restricted by, amounts that would have
otherwise been paid under standard TRICARE reimbursement methodologies
outlined in this manual, (i.e., those reimbursement methodologies
applicable only to non-network providers). Contractors are free
to establish alternative reimbursement systems, except capitation
payments, that will ensure adequate beneficiary access to quality
network providers. These alternative reimbursement systems may include,
but are not restricted to:
• Negotiated
or discounted fee schedules; usual and customary fees;
• Salary,
flat fee, global or profit/risk sharing arrangements for non-institutional
providers; and
• Per diems for institutional
providers.
2.3 All claim
payments for individual services (whether network or non-network)
are subject to the maximum payment methodologies set forth by Federal
Law and outlined in this manual. Health care dollars may not be
used to pay amounts in excess of these maximum payment methodologies.
Note: The specific allowable amount
may vary based on beneficiary status (e.g., participation in demonstration)
or exact geographical location.