General
Chapter 1
Section 2
Accommodation Of Discounts
Under Provider Reimbursement Methods
Issue Date: December 7, 1990
Revision: C-6, October 20, 2017
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.
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