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 ISSUE
This policy is related to reimbursement
of covered beneficiary related services of individual health care
providers and professionals that would otherwise meet the qualifications
of individual health care providers except that they are either
employed by or under contract to an institutional provider, and
other non-institutional health care providers to be reimbursed.
3.0 POLICY
Covered services provided by
all TRICARE authorized individual health care providers and other
non-institutional health care providers shall be reimbursed using
the allowable charge methodology unless otherwise stated.
3.1 This policy applies to all
categories of individual health care providers and professionals
that would otherwise meet the qualifications of individual health
care providers except that they are either employed by or under
contract to an institutional provider, and other non-institutional
providers regardless of the beneficiary services provided.
3.2 This policy applies to all
locations, inpatient or outpatient, where services are provided
by these providers. These services could be provided by individual
health care providers in a Diagnosis Related Groups (DRG) hospital,
a DRG exempt hospital, an Ambulatory Surgery Center (ASC), or in
a facility without a TRICARE all-inclusive rate.
Note: Facility charges for inpatient
and outpatient services shall continue to be billed on the current
Centers for Medicare and Medicaid Services (CMS) 1450 UB-04. This
would include inpatient services that are and have been included
in the reimbursement under the DRG-based payment system or the mental
health per diem payment system. Outpatient facility charges would
include services that aid the individual health care provider in
the treatment of the beneficiary. These charges may include such
services as the use of hospital facilities factoring in overhead
costs of utilities, billing, equipment and maintenance costs, insurance,
nursing staff, including emergency room (ER) services (nonprofessional
services), the services of nurses, technicians, and other aides,
medical supplies (gauze, oxygen, ointments, dressings, splints,
casts, prosthetic devices), and drugs and biologicals which cannot
be self-administered.
3.3 Services
provided by individual authorized health care providers and other
non-institutional health care providers shall be billed only on
the current CMS 1500 Claim Form or the TRICARE 2642 for payment.
Individual health care providers (e.g., physicians) and non-institutional
providers (e.g., suppliers) are to use the CMS 1500 Claim Form.
Institutional providers (e.g., hospitals) are to use the CMS 1500
Claim Form or the CMS 1450 UB-04 (if adequate Common Procedure Terminology
(CPT) coding information is submitted) to bill for the professional component
of physicians and other authorized professional providers. Beneficiaries
(or their representatives) who complete and file their own claims
for individual health care providers and other non-institutional
health care provider services may want to use the TRICARE 2642 claim
form for payment.