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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
General
Chapter 1
Section 1
Network Provider Reimbursement
Issue Date:  July 1, 1998
Authority:  32 CFR 199.17(p)(6)
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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