Military Health System

1.1  The contractor shall follow this policy for reimbursing services provided by either network or non-network providers. However, the contractor may use alternative network reimbursement methodologies when approved by the Defense Health Agency (DHA) and the contractor specifically includes them in the network provider agreement.

1.2  This reimbursement policy applies to covered surgical procedures performed in freestanding Ambulatory Surgical Centers (FASCs).

1.3  The contractor shall not exempt ambulatory surgery services provided by FASCs in Maryland from this system and shall reimburse these services using the procedures set forth in this section.

2.1  An FASC is any distinct entity that is classified by the Centers for Medicare and Medicaid Services (CMS) as an ASC under 42 CFR part 416, and has an active participation agreement with both Medicare and TRICARE. FASCs that specifically serve pediatric populations and do not have a Medicare participation agreement, meet TRICARE’s ASC requirements when the facility:

2.2  The contractor shall ensure FASCs do not bill TRICARE beneficiaries for non-covered procedures, unless the beneficiary agreed in advance in writing to pay for the services.

3.1  Effective for service dates on or after October 1, 2023, TRICARE is adopting the Medicare ASC reimbursement system including their ASC fee schedule rules, payment rates, payment indicators, list of covered procedures and ancillary services, and wage indices.

3.2  The payment rates established under this system shall apply only to the facility charges for ambulatory surgery in an FASC. The contractor shall make facility payments to FASCs only for covered services listed on Medicare’s ASC list, except for Current Procedural Terminology (CPT) code 41899 and certain dental procedures. For covered dental procedures (e.g., CPT procedure code 41899), the contractor shall reimburse the ASC facility at the Outpatient Prospective Payment System (OPPS) rate. Refer to TRICARE Policy Manual (TPM), Chapter 8, Section 13.2 for dental care covered in an ASC. Additional services, which are not otherwise packaged into the OPPS payment for a covered dental procedure, and provided on a claim with covered a dental procedures will be subject to the payment methodology as described in this section.

3.3  The facility rate is a standard overhead amount that includes nursing and technician services; use of the facility; drugs, biologicals, and radiology services, for which separate payment is not allowed under OPPS; surgical dressings, splints, casts and equipment directly related to provision of the surgical procedure; materials for anesthesia; Intraocular Lenses (IOLs); and administrative, recordkeeping and housekeeping items and services.

3.4  This facility rate does not include items such as physicians’ fees (or fees of other professional providers authorized to render the services and to bill independently for them); certain laboratory, X-rays or diagnostic procedures for which separate payment is allowed under OPPS; orphan drugs; prosthetic devices (except IOLs); corneal acquisition tissue; brachytherapy services; certain implantable devices with pass-through status under OPPS; ambulance services; leg, arm, and back braces; artificial limbs; and Durable Medical Equipment (DME) for use in the patient’s home.

5.1  Facilities without a valid TRICARE participation agreement.

5.2  Facilities without a valid participation agreement with Medicare. This exclusion does not apply to facilities that only service pediatric patients.

5.3  Services and items not listed on Medicare’s ASC coverage list, except for certain dental procedures described in paragraph 3.2.