General
Chapter 1
Section 2
Accommodation
Of Discounts Under Provider Reimbursement Methods
Issue Date: December 7, 1990
Revision:
1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
2.0 POLICY
2.1 A provider
shall be reimbursed at an amount below the amount usually paid pursuant
to this chapter when the provider has agreed to the lower amount.
This applies only when both the provider and the DHA have agreed
to the discounted payment rates for non-network providers.
2.2 In the case of individual health
care professionals and other non-institutional providers, if the
discounted fee is below the provider’s normal billed charge and
the allowable charge level, the discounted fee shall be the provider’s
actual billed charge and the TRICARE allowable charge.
2.3 In the case of institutional
providers normally paid on the basis of a pre-set amount (such as
DRG-based amount or per diem amount), if the discount rate is lower
than the pre-set rate, the discounted rate shall be the TRICARE-determined
allowable cost. This is an exception to the usual rule that the
pre-set rate is paid regardless of the institutional provider’s
billed charges or other factors.
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