General
Chapter 1
Section 1
Network
Provider Reimbursement
Issue Date: July 1, 1998
Revision:
1.0 ISSUE
How are network providers to
be reimbursed under TRICARE?
2.0 POLICY
2.1 The contractor
shall make timely and accurate payments to all network providers
of care in accordance with the terms and conditions of their contracts.
Where required, the beneficiary deductibles and cost-shares must be
collected and accrued toward the catastrophic cap. Beneficiaries
cannot be exempt from payment of deductibles (except for beneficiaries
enrolled in TRICARE Prime and claims for prescription drugs obtained
from a network pharmacy) and cost-shares/copayments.
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 permitted to establish alternative
reimbursement systems, except capitation payments, that will ensure
adequate beneficiary access to quality network providers (also see
Chapter
18. 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.
- END -