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TRICARE Reimbursement Manual 6010.61-M, April 2015
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Table of Contents
Table of Contents
TRICARE Reimbursement Manual 6010.61-M, April 2015, Change 66 (January 6, 2023)
Foreword
Chap 1 -- General
Sect 1 -- Network Provider Reimbursement
Sect 2 -- Accommodation Of Discounts Under Provider Reimbursement Methods
Sect 3 -- Claims Auditing Software
Sect 4 -- Reimbursement In Teaching Setting
Sect 5 -- National Health Service Corps (NHSC) Physicians Of The Public Health Service (PHS)
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 Providers 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 Equipment (DE) And 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 Travel Expenses For Specialty Care
Sect 31 -- Newborn Charges
Sect 32 -- Hospital-Based Birthing Room
Sect 33 -- Bonus Payments In Health Professional Shortage Areas (HPSAs)
Sect 34 -- Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia
Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States (U.S.) And The District Of Columbia
Sect 36 -- Forensic Examinations Following Sexual Assault or Domestic Violence
Sect 37 -- Medical Errors
Sect 38 -- Reimbursement of State Vaccine Programs (SVPs)
Sect 39 -- CHAMPUS Maximum Allowable Charge (CMAC) For Banked Donor Milk (BDM)
Sect 40 -- Organ Acquisition Costs
Sect 41 -- Hospital Reimbursement - Hospital Value-Based Purchasing (HVBP)
Sect 42 -- Temporary Reimbursement Changes in Response to Coronavirus Disease 2019 (COVID-19) Pandemic
Addendum A -- Sample State Agency Billing Agreement
Addendum B -- Figures
Addendum C -- Minimum Requirements For Reimbursement Of Per Capita State (Or Alternative) State Vaccine Programs (SVPs)
Addendum D -- Maximum Allowable Charge For Breastfeeding Supplies
Chap 2 -- Beneficiary Liability
Sect 1 -- Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries
Sect 2 -- Cost-Shares And Deductibles For TRICARE Services Received On Or After January 1, 2018
Sect 3 -- Catastrophic Loss Protection For TRICARE Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018, By TRICARE For Life (TFL) Beneficiaries
Sect 4 -- Catastrophic Loss Protection For Services Rendered On Or After January 1, 2018
Sect 5 -- Point Of Service (POS) Option
Sect 6 -- Waivers of Cost-Shares and Deductibles
Sect 7 -- Temporary Waivers of Copayments and Cost-Shares (Including Deductibles) in Response to Coronavirus 2019 (COVID-19) Pandemic
Addendum A -- Benefits And Beneficiary Payments Under The TRICARE Program For Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries
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
Sect 7 -- No Government Pay Procedure Codes
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 -- Payment For Professional/Technical Components Of Diagnostic Services
Chap 6 -- Diagnosis Related Groups (DRGs)
Sect 1 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General)
Sect 2 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (General Description Of System)
Sect 3 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Basis Of Payment)
Sect 4 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Applicability Of The DRG System)
Sect 5 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Determination Of Payment Amounts)
Sect 6 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (DRG Weighting Factors)
Sect 7 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjusted Standardized Amounts (ASAs))
Sect 8 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts)
Sect 9 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Information Provided By Defense Health Agency (DHA))
Sect 10 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Charges To Beneficiaries)
Sect 11 -- Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (New Technology Add-On Payments (NTAPs))
Addendum A -- Health Benefit Program Agreement
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2015
Addendum B -- TRICARE Adjusted Standardized Amounts (ASAs) - FY 2016 And Beyond
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2015
Addendum C -- Diagnosis Related Groups (DRGs), DRG Relative Weights, Arithmetic And Geometric Mean Lengths-Of-Stay (LOS), And Short-Stay Outlier Thresholds - FY 2016 And Beyond
Chap 7 -- Mental Health
Sect 1 -- Hospital Reimbursement - TRICARE Inpatient Mental Health Per Diem Payment System
Sect 2 -- Partial Hospitalization Program (PHP) And Intensive Outpatient Program (IOP) Reimbursement: Mental Health And Substance Use Disorder (SUD) Treatment
Sect 3 -- Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRFs) Reimbursement
Sect 4 -- Psychiatric Residential Treatment Center (RTC) Reimbursement
Sect 5 -- Opioid Treatment Programs (OTPs) Reimbursement
Addendum A -- Table Of Regional Specific Rates For Psychiatric Hospitals And Units With Low TRICARE Volume - Fiscal Year (FY) 2020 - FY 2022
Addendum B -- Guidelines For The Calculation Of Individual Psychiatric Residential Treatment Center (RTC) Per Diem Rates
Chap 8 -- Skilled Nursing Facilities (SNFs)
Sect 1 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Services Received Prior To October 1, 2019
Sect 2 -- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) For Care Rendered On Or After October 1, 2019
Addendum A -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Received On Or After October 1, 2019
Addendum B -- Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement For Services Prior To October 1, 2019
Addendum C -- Resource Utilization Group-III /IV (RUG-III/IV) Resource Utilization Group-III/IV (RUG-III/IV) For Services Received Prior To October 1, 2019
Addendum D -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2018 For Services Received Prior To October 1, 2019
Addendum D -- Example Of Computation of Adjusted Prospective Payment System (PPS) Rates And Skilled Nursing Facility (SNF) Payment - FY 2019 For Services Received Prior To October 1, 2019
Addendum E -- Fact Sheet Regarding Consolidated Billing and Ambulance Services For Services Received Prior To October 1, 2019
Addendum F -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2018 For Services Received Prior To October 1, 2019
Addendum F -- Case-Mix Adjusted Federal Rates For Skilled Nursing Facilities (SNFs) - FY 2019 For Services Received Prior To October 1, 2019
Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2018 For Services Received Prior To October 1, 2019
Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2019 For Services Received Prior To October 1, 2019
Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2018 For Services Received Prior To October 1, 2019
Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas - FY 2019 For Services Received Prior To October 1, 2019
Chap 9 -- Ambulatory Surgery Centers (ASCs)
Sect 1 -- Ambulatory Surgical Center (ASC) 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
Sect 5 -- Hospice Reimbursement - Concurrent Hospice Services And Curative Care For Pediatric Beneficiaries
Addendum A -- Hospice Care Rates - FY 2020
Addendum A -- Hospice Care Rates - FY 2021
Addendum A -- Hospice Care Rates - FY 2022
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2020
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2021
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas - FY 2022
Addendum C -- HospiceRate Information - Hospice Wage Indexes For Rural Areas - FY 2020
Addendum C -- HospiceRate Information - Hospice Wage Indexes For Rural Areas - FY 2021
Addendum C -- HospiceRate Information - Hospice Wage Indexes For Rural Areas - FY 2022
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 (EOCs)
Sect 6 -- Home Health Benefit Coverage And Reimbursement - Claims And Billing Submission Under Home Health Agency Prospective Payment System (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
Sect 9 -- Home Health Benefit Coverage And Reimbursement - Under The Patient-Driven Groupings Model (PDGM)
Addendum A -- Definitions And Acronym Table
Addendum B -- Home Health Resource Group (HHRG) Worksheet
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2020
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2021
Addendum C -- Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2022
Addendum D -- Home Health Certification And Plan Of Care (POC)
Addendum E -- Code Table For Converting Julian Dates To Two Position Alphabetic Values
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 - Outpatient Code Editor (OCE)/APC And No Government Pay List (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)
Chap 16 -- Long-Term Care Hospitals (LTCHs)
Sect 1 -- Long-Term Care Hospitals (LTCHs)
Chap 17 -- Inpatient Rehabilitation Facilities (IRFs)
Sect 1 -- Inpatient Rehabilitation Facilities (IRFs)
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