2.2 Services or Supplies Specifically
Excluded from Payment
2.2.1 Non-Covered DRGs
The contractor must ensure
that TRICARE coverage requirements are met.
2.2.2 Services and Supplies Not Related
to the Treatment Regimen
Charges for services and supplies
specifically excluded from TRICARE payment and which are not related
to the treatment regimen (e.g., private room accommodation differential
if the private room was not medically necessary and was requested
by the beneficiary, or television/telephone charges) will be the
responsibility of the beneficiary. The contractor is not to reduce
the DRG-based allowance for these items, since the DRG-based payment
is the same whether or not the items are provided. However, the
hospital is permitted to bill the beneficiary for the items.
2.3 Hospital Days Beyond that Deemed
Medically Necessary
Under
the TRICARE DRG-based payment system, the DRG amount is considered
full payment for any hospital stay, regardless of length. If any
days of a stay are subsequently determined to be medically unnecessary,
the following actions are to be taken:
2.3.1 Medically
unnecessary days which are the hospital’s responsibility. If it
is determined that certain days of care were medically unnecessary
and the days are the fault of the hospital--that is, the hospital/physician
made no attempt to discharge the patient--the unnecessary days shall
be included in the DRG-based amount, and no additional payment can
be made. Nor is the contractor to recoup any amount. However, if
elimination of the unnecessary days causes the stay to become a
short-stay outlier, the contractor is to recoup any excess amounts
over the appropriate short-stay outlier payment.
2.3.2 Medically unnecessary days
which are the beneficiary’s responsibility. If medically unnecessary
days of care were provided at the insistence of the beneficiary
(or sponsor)--that is, the hospital/physician attempted to discharge
the beneficiary, but the beneficiary insisted on remaining in the
hospital--any charges for those days will be the responsibility
of the beneficiary. This applies to all such days, and to the difference
between the normal DRG-based payment and the short-stay outlier payment
if it is determined the stay should have been a short-stay outlier.