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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
Chapter 13
Section 5
Medical Review And Allowable Charge Review Under the Outpatient Prospective Payment System (OPPS)
Issue Date:  July 27, 2005
Authority:  10 USC 1079(j)(2) and 10 USC 1079(h)
This policy is mandatory for the reimbursement of services provided either by 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
To describe the medical review and allowable charge review of hospital outpatient claims.
3.1  Medical review under the hospital OPPS.
3.1.1  The methodology of review for outpatient claims does not change under the OPPS.
3.1.2  The goal of medical review is to identify inappropriate billing and to ensure that payment is not made for noncovered services. Contractors may review any claim at any time, including requesting medical records, to ensure that payment is appropriate.
3.2  All OPPS review of claims processing with the exception of the Inpatient Only Procedures List, would be considered allowable review.
4.0  Effective Date
May 1, 2009.
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