General
Chapter 1
Section 1
Network
Provider Reimbursement
Issue Date: July 1, 1998
Revision:
1.0 ISSUE
How are network providers to
be reimbursed under TRICARE?
2.0 POLICY
2.1 TRICARE
contractors must make timely and accurate payments to all network
providers of care in accordance with the terms and conditions of
their contracts. Where required, the beneficiary deductibles and
cost-shares must be collected and accrued toward the catastrophic
cap. Beneficiaries cannot be exempt from payment of deductibles
(except for beneficiaries enrolled in TRICARE Prime and claims for
prescription drugs obtained from a network pharmacy) and cost-shares/copayments.
2.2 Network provider reimbursement
is neither subject to, nor restricted by, amounts that would have
otherwise been paid under standard TRICARE reimbursement methodologies
outlined in this manual, (i.e., those reimbursement methodologies
applicable only to non-network providers). Contractors are free
to establish alternative reimbursement systems, except capitation
payments, that will ensure adequate beneficiary access to quality
network providers. These alternative reimbursement systems may include,
but are not restricted to:
• Negotiated or discounted fee
schedules; usual and customary fees;
• Salary, flat fee, global or
profit/risk sharing arrangements for non-institutional providers;
and
• Per diems for institutional
providers.
2.3 All claim
payments for individual services (whether network or non-network)
are subject to the maximum payment methodologies set forth by Federal
Law and outlined in this manual. Health care dollars may not be
used to pay amounts in excess of these maximum payment methodologies.
Note: The specific allowable amount
may vary based on beneficiary status (e.g., participation in demonstration)
or exact geographical location.
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