Manual Table of Contents

TRICARE/CHAMPUS Policy Manual 6010.47-M, December 1998, Change 12 (May 14, 1999)

  1. Collapse to hide TRICARE/CHAMPUS Policy Manual contentsManualTRICARE/CHAMPUS Policy Manual 6010.47-M, December 1998
    1. PDF FilePOL TOC (TRICARE/CHAMPUS Policy Manual)
    2. PDF FilePOL (Tricare/CHAMPUS Policy Manual)
    3. PDF FilePOL (Tricare/CHAMPUS Policy Manual)
    4. PDF FilePOL Foreword (TRICARE/CHAMPUS Policy Manual)
    5. PDF FilePOL Introduction (TRICARE/CHAMPUS Policy Manual)
    6. Expand to show POL Chap 1 TOC contentsPDF FilePOL Chap 1 TOC -- Medical Services (TRICARE/CHAMPUS Policy Manual)
      1. Expand to show POL Chap 2 TOC contentsPDF FilePOL Chap 2 TOC -- Anesthesia (TRICARE/CHAMPUS Policy Manual)
        1. Expand to show POL Chap 3 TOC contentsPDF FilePOL Chap 3 TOC -- Surgery And Related Services (TRICARE/CHAMPUS Policy Manual)
          1. Expand to show POL Chap 4 TOC contentsPDF FilePOL Chap 4 TOC -- Radiology (TRICARE/CHAMPUS Policy Manual)
            1. Expand to show POL Chap 5 TOC contentsPDF FilePOL Chap 5 TOC -- Pathology And Laboratory Services (TRICARE/CHAMPUS Policy Manual)
              1. Expand to show POL Chap 6 TOC contentsPDF FilePOL Chap 6 TOC -- Institutional Services (TRICARE/CHAMPUS Policy Manual)
                1. Expand to show POL Chap 7 TOC contentsPDF FilePOL Chap 7 TOC -- Other Services (TRICARE/CHAMPUS Policy Manual)
                  1. Expand to show POL Chap 8 TOC contentsPDF FilePOL Chap 8 TOC -- Special Benefit Information (TRICARE/CHAMPUS Policy Manual)
                    1. Expand to show POL Chap 9 TOC contentsPDF FilePOL Chap 9 TOC -- Eligibility Policy (TRICARE/CHAMPUS Policy Manual)
                      1. Expand to show POL Chap 10 TOC contentsPDF FilePOL Chap 10 TOC -- Provider Policy (TRICARE/CHAMPUS Policy Manual)
                        1. Expand to show POL Chap 11 TOC contentsPDF FilePOL Chap 11 TOC -- Administrative Policy (TRICARE/CHAMPUS Policy Manual)
                          1. Expand to show POL Chap 12 TOC contentsPDF FilePOL Chap 12 TOC -- TRICARE (TRICARE/CHAMPUS Policy Manual)
                            1. Collapse to hide POL Chap 13 TOC contentsPDF FilePOL Chap 13 TOC -- Payments Policy (TRICARE/CHAMPUS Policy Manual)
                              1. PDF FilePOL Chap 13 Sect 1.1 -- Allowable Charges - General (Tricare/CHAMPUS Policy Manual)
                              2. PDF FilePOL Chap 13 Sect 1.2 -- Allowable Charges - Application Of Criteria (Tricare/CHAMPUS Policy Manual)
                              3. PDF FilePOL Chap 13 Sect 1.3 -- Allowable Charges - Application Of The Maximum Allowable Prevailing Charge (Tricare/CHAMPUS Policy Manual)
                              4. PDF FilePOL Chap 13 Sect 1.3 -- 99000 Evaluation And Management Codes Addendum 1, Exhibit 1 (Tricare/CHAMPUS Policy Manual)
                              5. PDF FilePOL Chap 13 Sect 1.3 -- 99000 Evaluation And Management Codes Addendum 1, Exhibit 2 (Tricare/CHAMPUS Policy Manual)
                              6. PDF FilePOL Chap 13 Sect 1.3 -- 99000 Evaluation And Management Codes Addendum 1, Exhibit 3 (Tricare/CHAMPUS Policy Manual)
                              7. PDF FilePOL Chap 13 Sect 1.3 -- 99000 Evaluation And Management Codes Addendum 2 (Tricare/CHAMPUS Policy Manual)
                              8. PDF FilePOL Chap 13 Sect 1.3 -- Schedule For Paying 90000 And 99000 Series Codes Addendum 3 (Tricare/CHAMPUS Policy Manual)
                              9. PDF FilePOL Chap 13 Sect 1.4 -- Rebundling Of Procedure Codes (Tricare/CHAMPUS Policy Manual)
                              10. PDF FilePOL Chap 13 Sect 1.5 -- Allowable Charges - CHAMPUS Maximum Allowable Charges (CMAC) (Tricare/CHAMPUS Policy Manual)
                              11. PDF FilePOL Chap 13 Sect 1.5 -- Special Payment Situations Addendum 1 (Tricare/CHAMPUS Policy Manual)
                              12. PDF FilePOL Chap 13 Sect 2.1 -- Reimbursement In Teaching Setting (Tricare/CHAMPUS Policy Manual)
                              13. PDF FilePOL Chap 13 Sect 2.2 -- National Health Service Corps Physicians Of The Public Health Service (Tricare/CHAMPUS Policy Manual)
                              14. PDF FilePOL Chap 13 Sect 2.3 -- Medical Groups (Tricare/CHAMPUS Policy Manual)
                              15. PDF FilePOL Chap 13 Sect 2.4 -- Providers With Offices In More Than One Locality (Tricare/CHAMPUS Policy Manual)
                              16. PDF FilePOL Chap 13 Sect 2.5 -- Reimbursement Of Physician Assistants (Tricare/CHAMPUS Policy Manual)
                              17. PDF FilePOL Chap 13 Sect 2.6 -- Reimbursement Of Covered Services Provided By Individual Health-Care Professionals And Other Non-Institutional Health-Care Providers (Tricare/CHAMPUS Policy Manual)
                              18. PDF FilePOL Chap 13 Sect 2.7 -- Economic Interest In Connection With Mental Health Admissions (Tricare/CHAMPUS Policy Manual)
                              19. PDF FilePOL Chap 13 Sect 3.1 -- Anesthesia (Tricare/CHAMPUS Policy Manual)
                              20. PDF FilePOL Chap 13 Sect 3.1A -- Postoperative Pain Management (Tricare/CHAMPUS Policy Manual)
                              21. PDF FilePOL Chap 13 Sect 3.2 -- Durable Medical Equipment Claims: Basic Program (Tricare/CHAMPUS Policy Manual)
                              22. PDF FilePOL Chap 13 Sect 3.3 -- Oxygen And Related Supplies (Tricare/CHAMPUS Policy Manual)
                              23. PDF FilePOL Chap 13 Sect 3.4 -- Laboratory Services (Tricare/CHAMPUS Policy Manual)
                              24. PDF FilePOL Chap 13 Sect 3.5 -- Ambulance Services (Tricare/CHAMPUS Policy Manual)
                              25. PDF FilePOL Chap 13 Sect 3.6 -- Legend Drugs And Insulin (Tricare/CHAMPUS Policy Manual)
                              26. PDF FilePOL Chap 13 Sect 3.7 -- Surgery (Tricare/CHAMPUS Policy Manual)
                              27. PDF FilePOL Chap 13 Sect 3.7A -- Assistant Surgeons (Tricare/CHAMPUS Policy Manual)
                              28. PDF FilePOL Chap 13 Sect 3.8 -- Professional Services: Obstetrical Care (Tricare/CHAMPUS Policy Manual)
                              29. PDF FilePOL Chap 13 Sect 3.10 -- Skilled Nursing Services (Tricare/CHAMPUS Policy Manual)
                              30. PDF FilePOL Chap 13 Sect 4.1 -- Individual Consideration Cases (Tricare/CHAMPUS Policy Manual)
                              31. PDF FilePOL Chap 13 Sect 4.2 -- Charges For Provider Administrative Expenses (Tricare/CHAMPUS Policy Manual)
                              32. PDF FilePOL Chap 13 Sect 4.3 -- Rare Or Unusual Procedures (Tricare/CHAMPUS Policy Manual)
                              33. PDF FilePOL Chap 13 Sect 4.4 -- Payment For Professional/Technical Components Of Diagnostic Services (Tricare/CHAMPUS Policy Manual)
                              34. PDF FilePOL Chap 13 Sect 4.5 -- Psychotherapy Profile (Tricare/CHAMPUS Policy Manual)
                              35. PDF FilePOL Chap 13 Sect 4.6 -- Payment Levels For Adjustments (Tricare/CHAMPUS Policy Manual)
                              36. PDF FilePOL Chap 13 Sect 4.8 -- CPT Codes With Time Elements (Tricare/CHAMPUS Policy Manual)
                              37. PDF FilePOL Chap 13 Sect 5.1 -- Institutional Reimbursement - General (Tricare/CHAMPUS Policy Manual)
                              38. PDF FilePOL Chap 13 Sect 6.1A -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (General) (Tricare/CHAMPUS Policy Manual)
                              39. PDF FilePOL Chap 13 Sect 6.1B -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (General Description Of System) (Tricare/CHAMPUS Policy Manual)
                              40. PDF FilePOL Chap 13 Sect 6.1C -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Basis Of Payment) (Tricare/CHAMPUS Policy Manual)
                              41. PDF FilePOL Chap 13 Sect 6.1D -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Applicability Of The DRG System) (Tricare/CHAMPUS Policy Manual)
                              42. PDF FilePOL Chap 13 Sect 6.1E -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Determination Of Payment Amounts) (Tricare/CHAMPUS Policy Manual)
                              43. PDF FilePOL Chap 13 Sect 6.1F -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (DRG Weighting Factors) (Tricare/CHAMPUS Policy Manual)
                              44. PDF FilePOL Chap 13 Sect 6.1G -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Adjusted Standardized Amounts) (Tricare/CHAMPUS Policy Manual)
                              45. PDF FilePOL Chap 13 Sect 6.1H -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Adjustments To Payment Amounts) (Tricare/CHAMPUS Policy Manual)
                              46. PDF FilePOL Chap 13 Sect 6.1I -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Information Provided By TMA) (Tricare/CHAMPUS Policy Manual)
                              47. PDF FilePOL Chap 13 Sect 6.1J -- Hospital Reimbursement - TRICARE/CHAMPUS DRG-Based Payment System (Charges To Beneficiaries) (Tricare/CHAMPUS Policy Manual)
                              48. PDF FilePOL Chap 13 Sect 6.2 -- Hospital Reimbursement - Billed Charges Set Rates (Tricare/CHAMPUS Policy Manual)
                              49. PDF FilePOL Chap 13 Sect 6.3 -- Hospital Reimbursement - Other Than Billed Charges (Tricare/CHAMPUS Policy Manual)
                              50. PDF FilePOL Chap 13 Sect 6.4 -- Hospital Reimbursement - Payment When Only SNF Level Of Care Is Required (Tricare/CHAMPUS Policy Manual)
                              51. PDF FilePOL Chap 13 Sect 6.5 -- Hospital Reimbursement - TRICARE/CHAMPUS Inpatient Mental Health Per Diem Payment System (Tricare/CHAMPUS Policy Manual)
                              52. PDF FilePOL Chap 13 Sect 6.6 -- Pricing Of Supplemental Health Care Program (SHCP) Claims (Tricare/CHAMPUS Policy Manual)
                              53. PDF FilePOL Chap 13 Sect 6.7 -- Psychiatric Partial Hospitalization Program Reimbursement (Tricare/CHAMPUS Policy Manual)
                              54. PDF FilePOL Chap 13 Sect 6.8 -- Substance Use Disorder Rehabilitation Facilities Reimbursement (Tricare/CHAMPUS Policy Manual)
                              55. PDF FilePOL Chap 13 Sect 7.1 -- Skilled Nursing Facility (SNF) Reimbursement (Tricare/CHAMPUS Policy Manual)
                              56. PDF FilePOL Chap 13 Sect 8.1 -- Residential Treatment Center (RTC) Reimbursement (Tricare/CHAMPUS Policy Manual)
                              57. Expand to show POL Chap 13 Sect 9.1 contentsPDF FilePOL Chap 13 Sect 9.1 -- Ambulatory Surgical Center Reimbursement (Tricare/CHAMPUS Policy Manual)
                                1. PDF FilePOL Chap 13 Sect 10.1 -- Preferred Provider Organization (PPO) Reimbursement (Tricare/CHAMPUS Policy Manual)
                                2. PDF FilePOL Chap 13 Sect 11.1 -- Cost-Shares And Deductibles: TRICARE/CHAMPUS Standard (Tricare/CHAMPUS Policy Manual)
                                3. PDF FilePOL Chap 13 Sect 11.2 -- Cost-Shares And Deductibles: TRICARE/CHAMPUS DRG-Based Payment System (Tricare/CHAMPUS Policy Manual)
                                4. PDF FilePOL Chap 13 Sect 11.3 -- Cost-Shares And Deductibles: Former Spouses (Tricare/CHAMPUS Policy Manual)
                                5. PDF FilePOL Chap 13 Sect 11.4 -- Cost-Shares And Deductibles: Maternity (Tricare/CHAMPUS Policy Manual)
                                6. PDF FilePOL Chap 13 Sect 11.5 -- Cost-Shares And Deductibles: TRICARE/CHAMPUS Inpatient Mental Health Per Diem Payment System (Tricare/CHAMPUS Policy Manual)
                                7. PDF FilePOL Chap 13 Sect 11.6 -- Program For Persons With Disabilities (PFPWD): Cost-Shares And Deductibles (Tricare/CHAMPUS Policy Manual)
                                8. PDF FilePOL Chap 13 Sect 11.7 -- Waiver Of Cost-Sharing And Deductible (Tricare/CHAMPUS Policy Manual)
                                9. PDF FilePOL Chap 13 Sect 11.8 -- Cost-Shares And Deductibles: Ambulatory Surgery (Tricare/CHAMPUS Policy Manual)
                                10. PDF FilePOL Chap 13 Sect 12.1 -- Double Coverage (Tricare/CHAMPUS Policy Manual)
                                11. PDF FilePOL Chap 13 Sect 13.1 -- Health Maintenance Organizations (HMOs) (Tricare/CHAMPUS Policy Manual)
                                12. PDF FilePOL Chap 13 Sect 13.2 -- Managed Care Claims (Tricare/CHAMPUS Policy Manual)
                                13. PDF FilePOL Chap 13 Sect 13.3 -- Pre-Paid Prescription Plans (Tricare/CHAMPUS Policy Manual)
                                14. PDF FilePOL Chap 13 Sect 14.1 -- Catastrophic Loss Protection (Tricare/CHAMPUS Policy Manual)
                                15. PDF FilePOL Chap 13 Sect 15.1 -- Emergency Care Related Claims (Tricare/CHAMPUS Policy Manual)
                                16. PDF FilePOL Chap 13 Sect 15.2 -- Organ Transplantation Related Claims (Tricare/CHAMPUS Policy Manual)
                                17. Expand to show POL Chap 13 Sect 16.1 contentsPDF FilePOL Chap 13 Sect 16.1 -- Waiver Of Liability (Tricare/CHAMPUS Policy Manual)
                                  1. PDF FilePOL Chap 13 Sect 17.1 -- PRO Preadmission Review (Tricare/CHAMPUS Policy Manual)
                                  2. PDF FilePOL Chap 13 Sect 18.1 -- Accommodation Of Discounts Under Provider Reimbursement Methods (Tricare/CHAMPUS Policy Manual)
                                  3. PDF FilePOL Chap 13 Sect 19.1 -- VA Changes In Application Of Deductibles And Catastrophic Cap Limitations (Tricare/CHAMPUS Policy Manual)
                                  4. PDF FilePOL Chap 13 Sect 20.1 -- Legal Obligation To Pay (Tricare/CHAMPUS Policy Manual)
                                  5. PDF FilePOL Chap 13 Sect 21.1 -- Program For Persons With Disabilities (PFPWD) And Basic Program Concurrent Use (Tricare/CHAMPUS Policy Manual)
                                  6. PDF FilePOL Chap 13 Sect 21.2 -- Program For Persons With Disabilities (PFPWD): Claims (Tricare/CHAMPUS Policy Manual)
                                  7. PDF FilePOL Chap 13 Sect 22.1A -- Hospice Reimbursement - General Overview (Tricare/CHAMPUS Policy Manual)
                                  8. PDF FilePOL Chap 13 Sect 22.1B -- Hospice Reimbursement - Coverage/Benefits (Tricare/CHAMPUS Policy Manual)
                                  9. PDF FilePOL Chap 13 Sect 22.1C -- Hospice Reimbursement - Conditions For Coverage (Tricare/CHAMPUS Policy Manual)
                                  10. PDF FilePOL Chap 13 Sect 22.1D -- Hospice Reimbursement - Guidelines For Payment Of Designated Levels Of Care (Tricare/CHAMPUS Policy Manual)
                                  11. PDF FilePOL Chap 13 Sect 23.1 -- Provider Coding Of Non-Institutional Services Using HCPCS (Tricare/CHAMPUS Policy Manual)
                                  12. PDF FilePOL Chap 13 Sect 24.1 -- Reduction Of Payment For Noncompliance With Utilization Review Requirements (Tricare/CHAMPUS Policy Manual)
                                  13. PDF FilePOL Chap 13 Sect 25.1 -- Supplemental Insurance (Tricare/CHAMPUS Policy Manual)
                                  14. Expand to show POL Chap 13 Addendum 1 contentsPDF FilePOL Chap 13 Addendum 1 -- Health Benefit Program Agreement (Tricare/CHAMPUS Policy Manual)
                                    1. Expand to show POL Chap 13 Addendum 3 contentsPDF FilePOL Chap 13 Addendum 3 -- Table Of Maximum Rates For Partial Hospitalization Programs (Tricare/CHAMPUS Policy Manual)
                                      1. PDF FilePOL Chap 13 Addendum 7 -- Guidelines For The Calculation Of Individual Residential Treatment Center (RTC) Per Diem Rates (Tricare/CHAMPUS Policy Manual)
                                    2. PDF FilePOL Chap A Appendix A-1 -- TRICARE-Authorized Residential Treatment Centers (TRICARE/CHAMPUS Policy Manual)
                                    3. PDF FilePOL -- For payment of services provided on or after October 1, 1994 Appendix A-1 -- TRICARE-Authorized Residential Treatment Centers (TRICARE/CHAMPUS Policy Manual)
                                    4. PDF FilePOL -- For payment of services provided on or after April 6, 1995 Appendix A-2 -- TRICARE-Authorized Residential Treatment Centers (TRICARE/CHAMPUS Policy Manual)
                                    5. PDF FilePOL -- Following are the rate adjustments for those RTCs whose 1995 per diems were below the 30th percentile of all established fiscal year 1995 rates. The rates were adjusted by the lesser of the Consumer Price Index - Urban Wage Earners (CPI-U) for medi
                                    6. PDF FilePOL -- Following are the rate adjustments for those RTCs whose 1995 per diems were below the 30th percentile of all established fiscal year 1995 rates. The rates were adjusted by the lesser of the Consumer Price Index - Urban Wage Earners (CPI-U) for medi
                                    7. PDF FilePOL -- For payment of services provided on or after October 1, 1997. Appendix A-5 -- TRICARE-Authorized Residential Treatment Centers (TRICARE/CHAMPUS Policy Manual)
                                    8. PDF FilePOL -- For payment of services provided on or after October 1, 1998. Appendix A-6 -- TRICARE-Authorized Residential Treatment Centers (TRICARE/CHAMPUS Policy Manual)
                                    9. PDF FilePOL Chap B (TRICARE/CHAMPUS Policy Manual)
                                    10. PDF FilePOL Appendix B -- Participation Agreement For Freestanding Or Institution-Affiliated Birthing Center Maternity Care Services For TRICARE/CHAMPUS Beneficiaries (TRICARE/CHAMPUS Policy Manual)
                                    11. PDF FilePOL (TRICARE/CHAMPUS Policy Manual)
                                    12. PDF FilePOL Appendix C -- TRICARE/CHAMPUS Standards For Residential Treatment Centers Serving Children And Adolescents (RTCs) (TRICARE/CHAMPUS Policy Manual)