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TRICARE Operations Manual 6010.62-M, April 2021
Supplemental Health Care Program (SHCP)
Chapter 17
Section 2
Providers Of Care
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
1.1  The SHCP payment structure applies to inpatient and outpatient medical claims submitted by civilian institutions, individual professional providers, suppliers, pharmacies, and other TRICARE-authorized providers for Civilian Health Care (CHC) rendered to Uniformed Service members and other SHCP-eligible individuals.
1.2  The contractor shall refer to network providers in accordance with Chapter 1, Section 3 for Market/Military Medical Treatment Facility (MTF)-referred care.
1.3  For care that is not Market/MTF referred (including care for Market/MTF enrollees), most patients covered by this Chapter will have undergone medical care prior to any contact with the Specified Authorization Staff (SAS) (Addendum A) or the contractor.
1.4  The contractor shall issue authorizations and assist in finding network providers when the patient initiates contact prior to treatment and the SAS has authorized the care being sought; if a network provider is not available, the referral will be made to a TRICARE-authorized provider.
1.5  The contractor shall, upon receiving an episode of care authorization from the SAS, record and enter the authorization to enable appropriate claims processing.
1.5.1  The contractor shall, if needed, assist the patient with locating a network provider or TRICARE-authorized provider (if available) for service determined eligible patients other than active duty (e.g., Reserve Officer Training Corps (ROTC), Reserve Component (RC)), foreign military).
1.5.2  The contractor shall assist patients requesting a provider change if this occurs during an episode of care authorization period. Patients will not be referred to SAS. No requirement exists for SAS to create a new care authorization.
1.6  Claims for active duty dental services in the 50 United States (US), the District of Columbia, and US territories and commonwealths will be processed and paid by the Active Duty Dental Program (ADDP) contractor.
1.7  The contractor shall process and pay claims for adjunctive dental care (or the TRICARE Overseas Program (TOP) contractor for overseas care).
2.1  The contractor may, in addition to receiving claims from civilian providers, receive SHCP claims from certain USFHP Designated Providers (DPs). The provisions of the SHCP will not apply to services furnished by a USFHP DP if the services are included as covered services under the current negotiated agreement between the USFHP DP and the Defense Health Agency (DHA) (this includes care for a USFHP enrollee).
2.2  The contractor shall pay for any services not included in the USFHP DP agreement in accordance with the requirements in this chapter.
2.3  The USFHP, administered by the DPs listed below, currently have negotiated agreements which provide the Prime benefit (inpatient and outpatient care). Since these facilities have the capability for inpatient services, DPs can submit claims which will be paid in accordance with applicable TRICARE reimbursement rules under the SHCP:
•  CHRISTUS Health, Houston, TX (which also includes):
•  St. Mary’s Hospital, Port Arthur, TX
•  St. John Hospital, Nassau Bay, TX
•  St. Joseph Hospital, Houston, TX
•  Martin’s Point Health Care, Portland, ME
•  Johns Hopkins Health Care Corporation, Baltimore, MD
•  Brighton Marine Health Center, Boston, MA
•  St. Vincent’s Catholic Medical Centers of New York, New York City, NY
•  Pacific Medical Clinics, Seattle, WA
The contractor may, in addition to receiving claims from civilian providers, receive SHCP claims from the DVA/VHA. The provisions of the SHCP will not apply to services provided under any Memorandum of Agreement (MOA) for sharing between the Department of Defense (DoD) (including the Army, Air Force, Navy/Marine Corps, and Coast Guard facilities) and the DVA/VHA. Claims for these services will continue to be processed by the Services.
3.1  The contractor shall, for any services not included in any MOA described below, pay claims in accordance with the TRICARE Reimbursement Manual (TRM) to include claims referred for beneficiaries on the Temporary Disability Retirement List (TDRL).
3.2  Claims for Care Provided Under the National DoD/DVA/VHA MOA for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation, and Polytrauma
3.2.1  The contractor shall process DVA/VHA submitted claims for eligible Service members’ treated under the MOA in accordance with this chapter (SCI, TBI MOA; see Addendum C for a full text copy of the MOA for references purposes only).
3.2.2  The contractor shall process claims received from a DVA/VHA health care facility for eligible Service member care as an MOA claim based upon the Defense Health Agency-Great Lakes (DHA-GL) SAS authorization number.  As determined by SAS, all medical conditions shall be authorized and paid under this MOA if a condition of TBI, SCI, Blindness, or Polytrauma exists for the patient.  The authorization shall clearly indicate that the care has been authorized under the SCI, TBI, Blindness, and Polytrauma MOA.  The authorization shall specify type of care (e.g., inpatient, outpatient) to be given under the referenced MOA and limits of the authorization (e.g., inpatient days, outpatient visits, expiration date).  Suggested authorization language to possibly include “all care authorized under the SCI, TBI, Blindness, and Polytrauma MOA” for inpatient, outpatient and rehabilitative care.  SAS shall send authorizations to the contractor either by fax or by other mutually agreed upon modality.
3.2.3  The contractor shall verify whether the DVA/VHA-provided care has been authorized by the SAS.
3.2.4  The contractor shall process the claim to payment if an authorization is on file.
3.2.5  The contractor shall not deny claims for lack of authorization. If a required authorization is not on file, the claim will be placed in a pending status.
3.2.6  The contractor shall forward the appropriate documentation to the SAS identifying the claim as a possible MOA claim for determination (following the procedures in the TRICARE Systems Manual (TSM), Chapter 1 for the SAS referral and review procedures).
3.2.7  The contractor shall pend claims to the SAS for payment determination for any DVA/VHA submitted claim for an eligible Service member with a TBI, SCI, blindness, or polytrauma condition that does not have a matching authorization number.
3.2.8  The contractor shall reimburse MOA claims as follows:  The contractor shall pay claims for inpatient care using DVA/VHA interagency rates, published in the Federal Register. The interagency rate is a daily per diem to cover inpatient stays and includes room and board, nursing, physician, and ancillary care. These rates will be provided to the contractor by DHA (including periodic updates as needed). There are three different interagency rates to be paid for rehabilitation care under the MOA. The Rehabilitation Medicine rate will apply to TBI care. Blind rehabilitation and SCI care each have their own separate interagency rate. Additionally, it is possible that two or more separate rates will apply to one inpatient stay. All interagency rates except the outpatient interagency rate in the Office of Management and Budget (OMB) Federal Register Notice provided by DHA will be applicable.  The contractor shall pay the claim using the separate rates if the DVA/VHA-submitted claim identifies more than one rate (with the appropriate number of days identified for each separate rate) (e.g., a stay for SCI may include days paid with the SCI rate and days billed at a surgery rate.)  The contractor shall verify the DVA/VHA billed rate on inpatient claims matches one of the interagency rates provided by DHA.  The contractor shall not develop DVA/VHA claims for inpatient care submitted with an applicable interagency rate any further (e.g., for revenue codes, diagnosis) if care has been approved by the DHA/SAS.  Claims without an applicable interagency rate shall be denied and an Explanation of Benefits (EOB) shall be issued to the DVA/VHA, but not the beneficiary. The claim will need to be resubmitted for payment.  The contractor shall pay claims for outpatient and ambulatory surgery professional services at the appropriate TRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC)) with a 10% discount applied.  The contractor shall pay DVA/VHA claims at billed charges for services without a TRICARE allowable rate.  The following care services, irrespective of health care delivery setting require authorization from SAS and are reimbursed at billed charges (actual DVA/VHA cost) separately from DVA/VHA inpatient interagency rates, if one exists:
•  Transportation
•  Prosthetics
•  Non-medical rehabilitative items
•  Durable Equipment (DE) and Durable Medical Equipment (DME)
•  Orthotics (including cognitive devices)
•  Routine and adjunctive dental services
•  Optometry
•  Lens prescriptions
•  Inpatient or outpatient TBI evaluations
•  Special diagnostic procedures
•  Inpatient or outpatient polytrauma transitional rehabilitation program
•  Home care
•  Personal care attendants
•  Conjoint family therapy
•  Ambulatory surgeries
•  Cognitive rehabilitation
•  Extended care including nursing home care  The contractor shall process all claims received on or after this date using the guidelines established under the updated MOA regardless of the date of service. All TRICARE Encounter Data (TED) records for this care shall include Special Processing Code (SPC) 17 - DVA/VHA medical provider claim.  If paid at per diem rates, the provisions of Chapter 8, Section 2, apply when enrollment changes in the middle of an inpatient stay. If enrollment changes retroactively, prior payments will not be recouped.
3.3  Claims for Care Provided Under the National DoD/DVA/VHA MOA for Payment for Processing Disability Compensation and Pension Examinations (DCPE) in the Integrated Disability Evaluation System (IDES)
3.3.1  The contractor shall reimburse the DVA/VHA for services provided under the current national DoD/DVA/VHA MOA for “Processing Payment for Disability Compensation and Pension Examinations in the Integrated Disability Evaluation System” (IDES MOA; see Addendum B for a full text copy of the MOA for reference purposes only).
3.3.2  The contractor shall process claims under the IDES MOA in accordance with this chapter and the following:  Claims submitted by any DVA/VHA facility/provider for an eligible Service member’s care with the Current Procedural Terminology (CPT) code of 99456, International Classification of Diseases, 9th Revision (ICD-9) Diagnostic code of V68.01, or International Classification of Diseases, 10th Revision (ICD-10) diagnostic code of Z02.71 (Disability Examination) shall be processed as an IDES MOA claim. IDES MOA claims are SHCP claims.  The contractor shall consider the referral as a blanket authorization to process claims from any billing DVA/VHA facility or provider for authorized/DCPE exams and associated ancillary services under the IDES MOA, although the Market/MTF referral will specify a particular DVA/VHA facility/provider to provide the IDES MOA services.  The Market/MTF will generate a single referral and submit the referral to the contractor. The Market/MTF will complete the referral as described in Chapter 7, Section 5.  The referral will specify the total number of Compensation and Pension (C&P) examinations authorized for payment by the contractor. It is not necessary for the referral to identify the various specialists who will render the different C&P examinations. The reason for referral will be entered by the Market/MTF as “DVA/VHA only: Disability Evaluation System (DES) C&P exams for fitness for duty determination - total.
3.3.3  The DVA/VHA will list one C&P examination (CPT code 99456) per the appropriate field of the claim form and indicate one unit such that there is a separate line item for each C&P examination.
3.3.4  Related ancillary services may be billed on the same claim form or on a separate claim form identified by the single diagnosis of ICD-9/ICD-10 diagnostic code, V68.01/Z02.71 (Disability Examination).
3.3.5  The contractor shall process the claim to payment (refer to paragraph 2.3) if an IDES MOA claim is received from the DVA/VHA (paragraph 3.2.1) and an authorization to any DVA/VHA provider is on file). One C&P examination fee will be paid for each referred and authorized C&P examination up to the total number of C&P examinations authorized by the referring Market/MTF.
3.3.6  The contractor shall verify that the claim contains CPT code 99456 or ICD-9/ICD-10 code V68.01/Z02.71, and process the claim to payment, if an IDES MOA claim is received from the DVA/VHA (paragraph 3.2.1) and no authorization is on file.
3.3.7  The contractor shall process all claims for C&P exams as SHCP using the pricing provisions agreed upon in the IDES MOA. CPT code 99456 shall be used and will be considered to include all parts of each C&P examination, except ancillary services.
3.3.8  Claims for related ancillary services shall be paid at the appropriate TRICARE allowable rate (e.g., CMAC) with a 10% discount applied.
Figure 17.2-1  Disability Exam Pay Schedule
Effective Date
C&P Disability Exam (99456)
ancillary services
CMAC - 10%
3.3.9  The contractor’s TED records for this care shall include SPC DC (C&P Examinations-DVA/VHA), SPC 17 (VA Medical Provider Claim), and Enrollment Health Plan Code SR (SHCP-Market/MTF Referred Care).
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