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TRICARE Policy Manual 6010.63-M, April 2021
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) 114-328
Revision:  
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 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.
3.1.2  The Dosage Based SVP must enter into a participation agreement as delineated in Section 12.3.
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 United States (CONUS) to include Alaska and Hawaii, the Commonwealth of Puerto Rico, and all US territories. Information regarding Per Capita Based SVPs not apply to the TRICARE Medicare Eligible Program (TMEP) or TRICARE Overseas Program (TOP).
4.0  Reimbursement Of SVPs
See the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 38 for reimbursement of Dosage Based SVPs and Per Capita Based SVPs.
5.0  Effective Dates
An 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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