Military Health System

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:

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.