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TRICARE Reimbursement Manual 6010.58-M, February 2008
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Table of Contents
Table of Contents
TRICARE Reimbursement Manual 6010.58-M, February 2008, Change 78 (January 31, 2013)
Master TOC
Foreword
Chap 1 -- General
Sect 1 -- Network Provider Reimbursement
Sect 2 -- Accommodation Of Discounts Under Provider Reimbursement Methods
Sect 4 -- Reimbursement In Teaching Setting
Sect 3 -- Claims Auditing Software
Sect 5 -- National Health Service Corps Physicians Of The Public Health Service
Sect 6 -- Reimbursement Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified Psychiatric Nurse Specialists (CPNSs)
Sect 7 -- Reimbursement Of Covered Services Provided By Individual Health Care Professionals And Other Non-Institutional Health Care Providers
Sect 8 -- Economic Interest In Connection With Mental Health Admissions
Sect 9 -- Anesthesia
Sect 10 -- Postoperative Pain Management - Epidural Analgesia
Sect 11 -- Claims for Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (DMEPOS)
Sect 12 -- Oxygen And Related Supplies
Sect 13 -- Laboratory Services
Sect 14 -- Ambulance Services
Sect 15 -- Legend Drugs And Insulin
Sect 16 -- Surgery
Sect 17 -- Assistant Surgeons
Sect 18 -- Professional Services: Obstetrical Care
Sect 19 -- Charges For Provider Administrative Expenses
Sect 20 -- State Agency Billing
Sect 21 -- Hospital Reimbursement - Billed Charges Set Rates
Sect 22 -- Hospital Reimbursement - Other Than Billed Charges
Sect 23 -- Hospital Reimbursement - Payment When Only Skilled Nursing Facility (SNF) Level Of Care Is Required
Sect 24 -- Hospital Reimbursement - Outpatient Services
Sect 25 -- Preferred Provider Organization (PPO) Reimbursement
Sect 26 -- Supplemental Insurance
Sect 27 -- Legal Obligation To Pay
Sect 28 -- Reduction Of Payment For Noncompliance With Utilization Review Requirements
Sect 29 -- Reimbursement Of Emergency Inpatient Admissions To Unauthorized Facilities
Sect 30 -- Reimbursement Of Certain Prime Travel Expenses For Specialty Care Over 100 Miles Away
Sect 31 -- Newborn Charges
Sect 32 -- Hospital-Based Birthing Room
Sect 33 -- Bonus Payments In Health Professional Shortage Areas (HPSAs) And In Physician Scarcity Areas (PSAs)
Sect 34 -- Hospital Inpatient Reimbursement In Locations Outside The 50 United States And The District Of Columbia
Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States And The District Of Columbia
Sect 36 -- Forensic Examinations Following Sexual Assault or Domestic Violence
Sect 37 -- Medical Errors
Addendum A -- Sample State Agency Billing Agreement
Addendum B -- Figures
Chap 2 -- Beneficiary Liability
Sect 1 -- Cost-Shares And Deductibles
Sect 2 -- Catastrophic Loss Protection
Sect 3 -- Point Of Service (POS) Option
Addendum A -- Benefits And Beneficiary Payments Under The TRICARE Program
Addendum B -- Pharmacy Benefits Program - Cost-Shares
Chap 3 -- Operational Requirements
Sect 1 -- Reimbursement Of Individual Health Care Professionals And Other Non-Institutional Health Care Providers
Sect 2 -- Hospital And Other Institutional Reimbursement
Sect 3 -- Discounts
Sect 4 -- Payment Reduction
Sect 5 -- Reimbursement Administration
Sect 6 -- Processing And Payment Of Home Infusion Claims Before January 30, 2012
Sect 7 -- Processing And Payment Of Home Infusion Claims On Or After January 30, 2012
Chap 4 -- Double Coverage
Sect 1 -- Double Coverage
Sect 2 -- Double Coverage Review And Processing Of Claims
Sect 3 -- Coordination Of Benefits (COB)
Sect 4 -- Specific Double Coverage Actions
Chap 5 -- Allowable Charges
Sect 1 -- Providers
Sect 2 -- Locality-Based Reimbursement Rate Waiver
Sect 3 -- CHAMPUS Maximum Allowable Charges (CMAC)
Sect 4 -- Individual Consideration Cases
Sect 5 -- Payment For Professional/Technical Components Of Diagnostic Services
Chap 6 -- Diagnostic Related Groups (DRGs)
Sect 1 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (General)
Sect 2 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (General Description Of System)
Sect 3 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment)
Sect 4 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Applicability Of The DRG System)
Sect 5 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Determination Of Payment Amounts)
Sect 6 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (DRG Weighting Factors)
Sect 7 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Adjusted Standardized Amounts (ASAs))
Sect 8 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Adjustments To Payment Amounts)
Sect 9 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Information Provided By TMA)
Sect 10 -- Hospital Reimbursement - TRICARE DRG-Based Payment System (Charges To Beneficiaries)
Addendum A -- Health Benefit Program Agreement
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2011
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2012
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2013
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2011
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2012
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2013
Chap 7 -- Mental Health
Sect 1 -- Hospital Reimbursement - TRICARE Inpatient Mental Health Per Diem Payment System
Sect 2 -- Psychiatric Partial Hospitalization Program (PHP) Reimbursement
Sect 3 -- Substance Use Disorder Rehabilitation Facilities (SUDRFs) Reimbursement
Sect 4 -- Residential Treatment Center (RTC) Reimbursement
Addendum A -- Table Of Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume - FY 2011 - FY 2013
Addendum B -- Table Of Maximum Rates For Freestanding Psychiatric Partial Hospitalization Programs (PHPs) Reimbursement - FY 2011 - FY 2013
Addendum C -- Guidelines For The Calculation Of Individual Residential Treatment Center (RTC) Per Diem Rates
Addendum D -- TRICARE-Authorized Residential Treatment Centers (RTCs) - FY 2011
Addendum D -- TRICARE-Authorized Residential Treatment Centers (RTCs) - FY 2012
Addendum D -- TRICARE-Authorized Residential Treatment Centers (RTCs) - FY 2013
Chap 8 -- Skilled Nursing Facilities (SNFs)
Sect 1 -- Skilled Nursing Facility (SNF) Reimbursement
Sect 2 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS)
Addendum A -- Resource Utilization Group-III /IV (RUG-III/IV)
Addendum B -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2011
Addendum B -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2012
Addendum B -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2013
Addendum C -- Fact Sheet Regarding Consolidated Billing and Ambulance Services
Addendum D -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2011
Addendum D -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2012
Addendum D -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2013
Addendum E -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2011
Addendum E -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2012
Addendum E -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2013
Addendum F -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2011
Addendum F -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2012
Addendum F -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2013
Addendum G -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement
Chap 9 -- Ambulatory Surgery Centers (ASCs)
Sect 1 -- ASC Reimbursement Before May 1, 2009 (Implementation Of OPPS), And Thereafter, Freestanding ASCs, And Non-OPPS Facilities Reimbursement
Chap 10 -- Birthing Centers
Sect 1 -- Freestanding And Hospital-Based Birthing Center Reimbursement
Addendum A -- Birthing Center Rate Non-Professional Component
Chap 11 -- Hospice
Sect 1 -- Hospice Reimbursement - General Overview
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Sect 3 -- Hospice Reimbursement - Conditions For Coverage
Sect 4 -- Hospice Reimbursement - Guidelines For Payment Of Designated Levels Of Care
Addendum A -- Hospice Care Rates - FY 2011
Addendum A -- Hospice Care Rates - FY 2012
Addendum A -- Hospice Care Rates - FY 2013
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2011
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2012
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2013
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas - FY 2011
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas - FY 2012
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas - FY 2013
Addendum D -- Participation Agreement For Hospice Program Services For TRICARE Beneficiaries
Chap 12 -- Home Health Care (HHC)
Sect 1 -- Home Health Benefit Coverage And Reimbursement - General Overview
Sect 2 -- Home Health Care (HHC) - Benefits And Conditions For Coverage
Sect 3 -- Home Health Benefit Coverage And Reimbursement - Assessment Process
Sect 4 -- Home Health Benefit Coverage And Reimbursement - Prospective Payment Methodology
Sect 5 -- Home Health Benefit Coverage And Reimbursement - Primary Provider Status And Episodes Of Care
Sect 6 -- Home Health Benefit Coverage And Reimbursement - Claims And Billing Submission Under HHA PPS
Sect 7 -- Home Health Benefit Coverage And Reimbursement - Pricer Requirements And Logic
Sect 8 -- Home Health Benefit Coverage And Reimbursement - Medical Review Requirements
Addendum A -- Definitions And Acronym Table
Addendum B -- Home Health Consolidated Billing Code List - Non-Routine Supply (NRS) Codes
Addendum C -- Home Health Consolidated Billing Code List - Therapy Codes
Addendum D -- CMS Form 485 - Home Health Certification And Plan Of Care (POC) Data Elements
Addendum E -- Primary Components Of A Home Care Patient Assessment
Addendum F -- Outcome And Assessment Information Set (OASIS-B1)
Addendum G -- Outcome and Assessment Information Set (OASIS) Items Used For Assessments Of 60-Day Episodes
Addendum H -- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Diagnosis Codes For Home Health Resource Group (HHRG) Assignment
Addendum I -- Home Health Resource Group (HHRG) Worksheet
Addendum J -- Health Insurance Prospective Payment System (HIPPS) Tables For Pricer
Addendum K -- Home Assessment Validation and Entry (HAVEN) Reference Manual
Addendum L -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2010
Addendum L -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2011
Addendum L -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2012
Addendum M -- Annual Home Health Agency Prospective Payment System (HHA PPS) Wage Index Updates - CY 2010
Addendum M -- Annual Home Health Agency Prospective Payment System (HHA PPS) Wage Index Updates - CY 2011
Addendum M -- Annual Home Health Agency Prospective Payment System (HHA PPS) Wage Index Updates - CY 2012
Addendum N -- Diagnoses Associated With Each Of The Diagnostic Categories Used In Case-Mix Scoring - CY 2008
Addendum O -- Diagnoses Included In The Diagnostic Categories Used For The Non-Routine Supplies (NRS) Case-Mix Adjustment Model
Addendum P -- Code Table For Converting Julian Dates To Two Position Alphabetic Values
Addendum Q -- Examples Of Claims Submission Under Home Health Agency Prospective Payment System (HHA PPS)
Addendum R -- Input/Output Record Layout
Addendum S -- Decision Logic Used By The Pricer For Episodes Beginning On Or After January 1, 2008
Chap 13 -- Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
Sect 1 -- General
Sect 2 -- Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
Sect 3 -- Prospective Payment Methodology
Sect 4 -- Claims Submission And Processing Requirements
Sect 5 -- Medical Review And Allowable Charge Review Under the Outpatient Prospective Payment System (OPPS)
Addendum A -- Development Schedule For TRICARE Outpatient Code Editor (OCE)/Ambulatory Payment Classification (APC) Quarterly Update
Addendum B -- Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Notification Process For Quarterly Updates
Addendum C -- Approval of OPPS - OCE/APC And NGPL Quarterly Update Process
Chap 14 -- Sole Community Hospitals (SCHs)
Sect 1 -- Sole Community Hospitals (SCHs)
Chap 15 -- Critical Access Hospitals (CAHs)
Sect 1 -- Critical Access Hospitals (CAHs)
Acronyms And Abbreviations
Index
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