Military Health System

4.1.1  The national prevailing charge was calculated by using the 80th percentile of all the billed charges during the 12 month period ending June 30, 2017. In the process of calculating the national prevailing charge, DHA removed outliers that were above an upper limit threshold of what the Government established to be “customary and reasonable”, in accordance with 32 CFR 199.9 definitions of abusive and excessive charges.

4.1.2  The national prevailing charge for these items are in Figure 1.D-1 and TRICARE Overseas Program (TOP) Figure 1.D-2. To account for local currency, exchange rate fluctuation, limits on availability, shipping, and other considerations, for claims that are processed under the TOP the national prevailing charge for the electric breast pump (HCPCS E0603) is $500 and twice the rate established for the other supplies. The contractor shall only apply TOP rates to items purchased overseas (all locations outside of the 50 United States and the District of Columbia) and received from an overseas supplier. The contractor shall apply rates in Figure 1.D-1 to suppliers located in the United States who ship overseas.

4.1.3  DHA will publish updates to the national prevailing charge annually, and adjust rates by the same update factor used to update the annual CHAMPUS Maximum Allowable Charge (CMAC) file. The contractor shall not wage adjust these rates for localities.

4.1.4  Effective with the 2019 CMAC update and subsequent updates, DHA will include the updated rates for these items in the annual CMAC file that is supplied to the contractors. The annual update usually takes place February 1. However, circumstances may cause the updates to be delayed. DHA will notify the contractor when the annual update is delayed. Effective for service dates on or after July 1, 2021, refer to Section 11 for annual and periodic adjustments to these rates.

4.1.5  DHA will not publish future pricing in this manual, since DHA will provide the most up-to-date rates at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Durable-Medical-Equipment-Prosthetics-Orthotics-and-Supplies.

4.2.1  The Government set the national prevailing charge at the upper limit of what the Government has established as a “customary and reasonable” charge, in accordance with the definitions of abusive and excessive billing practices found in 32 CFR 199.9.

4.2.2  The national prevailing charge for these items are in Figure 1.D-3 and TOP Figure 1.D-4. The TOP rates shall only apply to items that are purchased overseas (all locations outside of the 50 United States and the District of Columbia) and received from an overseas supplier. The contractor shall only apply the rates in Figure 1.D-3 to suppliers located in the United States who ship overseas.

4.2.3  DHA will publish updates to the national prevailing charge annually, and adjust the rates by the same update factor used to update the annual CMAC file. The contractor shall not wage adjust these rates for localities. Effective July 1, 2021, DHA will publish updates annually on January 1, and use the same update factor used in Medicare’s DMEPOS fee schedule.

4.2.4  DHA will not supply updated rates for these items in the annual CMAC file.

4.2.5  DHA will not publish future pricing in this manual since DHA will provide the most up-to-date rates at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Durable-Medical-Equipment-Prosthetics-Orthotics-and-Supplies.