Providers
Chapter 11
Section 9.2
State
Vaccine Programs (SVPs) As TRICARE-Authorized Providers
Issue Date:
Authority:
32 CFR 199.6(d)(5), National Defense Authorization
Act for Fiscal Year 2017 (NDAA FY 2017), Public Law (PL) 114-328
Revision:
1.0 ISSUE
Can State Vaccine Programs
or State Vaccine Program entities (SVPs) be certified under TRICARE
and reimbursed for supplied vaccines used to immunize TRICARE beneficiaries?
2.0 Background
2.1 SVPs are
state entities that supply vaccines at no cost to immunization providers
who use these vaccines to immunize children who reside in the state.
SVPs do not administer individual immunizations. Rather, these entities
simply supply the vaccines used in immunizations.
2.2 In order for an SVP to be reimbursed
for supplied vaccines used to immunize TRICARE beneficiaries the SVP
must be certified as a TRICARE-authorized provider.
32 CFR 199.6(d) lists those providers considered
as “other providers” under the TRICARE program. Furthermore,
32 CFR 199.6(d)(5) allows TRICARE-authorized
provider status for any firm, supplier, or provider that is an authorized
provider under Medicare or is otherwise designated as authorized
by the Defense Health Agency (DHA).
2.3 On May
20, 2014, a Decision Paper was signed by the Director, DHA to allow
an SVP to be certified as a TRICARE-authorized supplier of vaccines
under
32 CFR 199.6(d)(5) when the SVP executes a
TRICARE Participation Agreement and agrees to comply with TRICARE
legal and program requirements. These are known as Dosage Based
SVPs.
2.4 On December
23, 2016, based on the authority provided in the NDAA FY 2017, Section
719, a Decision Paper was signed by the Director, DHA to extend
certification as a TRICARE-authorized supplier of vaccines under
32 CFR 199.6(d)(5) to all other SVPs which
agree to be reimbursed on a per capita assessment without executing
a participation agreement. These are known as Per Capita Based SVPs.
3.0 Policy
3.1 A Dosage
Based SVP may be certified as a TRICARE-authorized provider under
the “other” category of provider as a supplier of vaccines when
all of the following specific requirements are met:
3.1.1 The Dosage
Based SVP must hold a valid National Provider Identification (NPI)
number.
3.1.2 The Dosage Based SVP must enter
into a participation agreement as delineated in
Section 12.3.
3.1.3 The SVP must agree to accept
the lesser of the TRICARE allowed amount or the billed charge in accordance
with
32 CFR 199.14 (i.e.,
the SVP-specific amount that is charged to other payers) as payment
in full for the vaccines supplied. The SVP must also agree to not
balance bill the beneficiary.
3.2 A Per
Capita Based SVP may be certified as a TRICARE-authorized provider
under the “other” category of provider as a supplier of vaccines.
3.3 Each contractor is the certifying
authority for SVPs located within their geographical jurisdiction,
to include obtaining the required participation agreement.
3.4 This policy applies to SVPs
and SVP entities located within the Continental United States (CONUS)
to include Alaska and Hawaii, the Commonwealth of Puerto Rico, and
all US territories. Information regarding Per Capita Based SVPs
not apply to the TRICARE Medicare Eligible Program (TMEP) or TRICARE
Overseas Program (TOP).
4.0 Reimbursement Of SVP
sSee the TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 38 for reimbursement of
Dosage Based SVPs and Per Capita Based SVPs.
5.0 Effective Dates
An SVP that meets the requirements
of this policy for Dosage Based SVP may be certified as a TRICARE-authorized supplier
of vaccines on or after May 20, 2014. The effective date for certification
of a specific SVP, for the purposes of claims reimbursement, is
the date the required participation agreement is signed. An SVP
that meets the requirements of this policy for Per Capita Based
SVP may be certified on or after December 23, 2016.
- END -