1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either 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 POLICY
2.1 A provider
shall be reimbursed at an amount below the amount usually paid pursuant
to this chapter when the provider has agreed to the lower amount.
This applies only when both the provider and the DHA have agreed
to the discounted payment rates for non-network providers.
2.2 In the case of individual health
care professionals and other non-institutional providers, if the discounted
fee is below the provider’s normal billed charge and the allowable
charge level, the discounted fee shall be the provider’s actual
billed charge and the TRICARE allowable charge.
2.3 In the case of institutional
providers normally paid on the basis of a pre-set amount (such as DRG-based
amount or per diem amount), if the discount rate is lower than the
pre-set rate, the discounted rate shall be the TRICARE-determined
allowable cost. This is an exception to the usual rule that the
pre-set rate is paid regardless of
the institutional provider’s billed charges or other factors.