Skip to main content
Military Health System
MHS Home
Utility Navigation Links
TRICARE.MIL
Main Navigation
Home
Manuals
Change History
Manuals by Date
Search
Help
Home
Manuals
TRICARE Program Manuals - 2021 Edition (T-5)
TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Policy Manual 6010.63-M, April 2021
TRICARE Reimbursement Manual 6010.64-M, April 2021
TRICARE Systems Manual 7950.4-M, April 2021
TRICARE Program Manuals - 2015 Edition (T-2017)
TRICARE Operations Manual 6010.59-M, April 2015
TRICARE Policy Manual 6010.60-M, April 2015
TRICARE Reimbursement Manual 6010.61-M, April 2015
TRICARE Systems Manual 7950.3-M, April 2015
Other Manuals
32 CFR 199 (DHA Version), December 2016
DoD Women, Infants, and Children (WIC) Overseas Program Policy Manual, July 2017
Duplicate Claims System (DCS) User Guide, June 2017
10 USC 55 (DHA Version), January 2007
Change History
Manuals by Date
Search
Help
Need larger text?
MHS Home
>
TRICARE Reimbursement Manual 6010.64-M, April 2021
>
Table of Contents
Table of Contents
TRICARE Reimbursement Manual 6010.64-M, April 2021, Change 2 (April 23, 2024)
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 (US) And The District Of Columbia
Sect 35 -- Professional Provider Reimbursement In Specified Locations Outside The 50 United States (US) 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 The 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 TRICARE Services Received 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 -- Chap 6 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) - Fiscal Year (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 - FY 2019 - FY 2021
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) 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 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)
Addendum G -- Wage Indexes For Urban Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas
Addendum H -- Wage Indexes For Rural Areas For Skilled Nursing Facilities (SNFs) Based On Core-Based Statistical Area (CBSA) Labor Market Areas
Chap 9 -- Ambulatory Surgery Centers (ASCs)
Sect 1 -- Chap 9 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 2 -- Hospice Reimbursement - Coverage/Benefits
Sect 2 -- Hospice Reimbursement - Coverage/Benefits
Addendum A -- Hospice Care Rates - FY 2019
Addendum A -- Hospice Care Rates - FY 2020
Addendum A -- Hospice Care Rates - FY 2021
Addendum B -- Hospice Rate Information - Hospice Wage Indexes For Urban Areas
Addendum C -- Hospice Rate Information - Hospice Wage Indexes For Rural Areas
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 - Primary Provider Status And Episodes/Periods Of Care
Sect 5 -- Home Health Benefit Coverage And Reimbursement - Medical Review Requirements
Sect 6 -- 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 2019
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 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 -- Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
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)
Chap 18 -- Alternate Payment Models (APMs)
Sect 1 -- Alternate Payment Models (APMs)
Sect 2 -- Low-Value Care (LVC) Medical Interventions
You are leaving Health.mil
The appearance of hyperlinks does not constitute endorsement by the Defense Health Agency of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website.
You are leaving Health.mil
View the external links disclaimer
.
OK
Cancel
Follow us on Instagram
Follow us on LinkedIn
Follow us on Facebook
Follow us on Twitter
Follow us on YouTube
Sign up on GovDelivery
Health.mil logo
Health.mil logo