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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
General
Chapter 1
Section 6
Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)
Issue Date:  July 9, 1990
Revision:  
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  ISSUE
How are PA, NP, and CPNS services to be reimbursed?
3.0  POLICY
3.1  The allowable charge for the services of the above listed providers may not exceed 85% of the allowable charge for a comparable service rendered by a physician. The employing physician of a PA must be an authorized TRICARE provider.
3.1.1  When the employing physician of a PA is not participating in a TRICARE reimbursement plan at less than the allowable charge determined under the provisions of Section 1, the allowable charge for the PA service may not exceed 85% of the allowable charge for the physician calculated in accordance with these provisions. When the PA and the physician perform component services of a procedure other than assistant-at-surgery (e.g., home, office or hospital visit components), the allowable charge for the procedure (to include both the services of the physician and PA) may not exceed the allowable charge for the procedure rendered by a physician.
3.1.2  When the employing physician is participating in a TRICARE reimbursement plan at less than the allowable charge as calculated in paragraph 3.1.1, the allowable charge for the PA service may not exceed 85% of the reduced allowable charge for the physician unless the reimbursement plan has specifically included use of PAs in the negotiated rates.
3.2  For services provided on or after July 27, 2012, the allowable charge for PA services performed as an assistant-at-surgery may not exceed 85% of the allowable charge for a physician serving as an assistant surgeon when authorized as TRICARE benefits in accordance with the provisions of 32 CFR 199.4(c)(3)(iii).
3.3  The allowable charge for NP services performed as an assistant-at-surgery may not exceed 85% of the allowable charge for a physician serving as an assistant surgeon when authorized as TRICARE benefits in accordance with the provisions of 32 CFR 199.4(c)(3)(iii).
3.4  The procedure or service performed by the PA is billed by the supervising or employing physician, billing it as a separately identified line item (e.g., PA Office Visit) and accompanied by the assigned PA provider number.
3.5  The procedure or service performed by the NP or CPNS is billed by the NP or CPNS. Unlike a PA, a NP or CPNS can bill on their own behalf. Like the PA, the NP or CPNS shall bill using an assigned NP provider number.
4.0  EFFECTIVE DATES
4.1  Reimbursement of PA services is effective for services rendered on or after July 1, 1990.
4.2  Reimbursement of NP services as stated above is effective for services rendered on or after September 1, 2003.
4.3  Reimbursement of CPNS services shall be 85% of the allowable amounts for physicians effective for services rendered on or after June 1, 2007.
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