1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
2.0 POLICY
2.1 A
provider shall be reimbursed at an amount below the amount usually
paid pursuant to this chapter when the provider has agreed to the
lower amount. This applies only when both the provider and the DHA
have agreed to the discounted payment rates for non-network providers.
2.2 In the case of individual health
care professionals and other non-institutional providers, if the discounted
fee is below the provider’s normal billed charge and the allowable
charge level, the discounted fee shall be the provider’s actual
billed charge and the TRICARE allowable charge.
2.3 In the case of institutional
providers normally paid on the basis of a pre-set amount (such as DRG-based
amount or per diem amount), if the discount rate is lower than the
pre-set rate, the discounted rate shall be the TRICARE-determined
allowable cost. This is an exception to the usual rule that the
pre-set rate is paid regardless of
the institutional provider’s billed charges or other factors.