Reimbursement

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Reimbursement

Health.mil is the source for all reimbursement rates for the TRICARE program. The information below will assist with determining TRICARE payment or Allowable Charge rates for TRICARE covered benefits determined by the TRICARE Policy and Reimbursement Manuals. The maximum amount that TRICARE can pay a provider for a procedure or service is known as the TRICARE allowable charge. The TRICARE allowable charge is tied by law to Medicare's allowable charge whenever practical and may vary based on the prevailing rate in a given location.

TRICARE For Life

TRICARE For Life (TFL) is a benefit available to retired U.S. Military and their families. It encompasses the processing of all TRICARE claims for services rendered within the 50 United States and the District of Columbia, as well as Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa and the Northern Mariana Islands, to individuals who have dual eligibility under both TRICARE and Medicare. Medicare and TFL work together to minimize the beneficiaries’ out-of-pocket expenses. Claims should be filed to Medicare first as the primary insurance.

There are instances when some health care costs may not be covered by Medicare and/or TFL. See the chart below which breaks down what the TRICARE For Life beneficiary should pay based on how the service is covered (please note that the chart below is the general rule and there are exceptions).

How the service is covered	What the beneficiary pays
By both Medicare and TRICARE For Life	Medicare pays first TRICARE For Life pays the remaining balance *The beneficiary pays nothing
By TRICARE For Life but not Medicare	TRICARE For Life pays first Medicare pays nothing *The beneficiary pays the TRICARE For Life calendar year deductible and cost shares
By Medicare but not TRICARE For Life	* Medicare pays first TRICARE For Life pays nothing The beneficiary pays the Medicare deductible and coinsurance
Not covered by Medicare or TRICARE For Life	* Medicare pays nothing TRICARE For Life pays nothing The beneficiary pays the entire bill

Coordinating TRICARE For Life with Other Health Insurance besides Medicare

How Medicare coordinates with Other Health Insurance (OHI) depends on whether or not the OHI is based on current employment. In either case, TRICARE For Life (TFL) is the last payer. If the beneficiary has OHI that is not based on their or their family member’s current employment, Medicare pays first, the OHI pays second, and TFL pays last.

What is covered?

TRICARE For Life and Medicare cover proven, medically necessary, and appropriate care. TFL has special rules and limitations for certain types of care, and some types of care are not covered at all. TFL policies are very specific about which services are covered and which are not.

For more information on what specific services are covered please visit TRICARE's what's covered page.

Medicare also has limits on the amount of care it covers and, in some cases TFL may cover these health care services after Medicare benefits run out. To determine if Medicare covers a specific service visit www.medicare.gov or call 1-800-633-4227.

Exclusions

Common examples of services excluded from TRICARE coverage:

Acupuncture
Assisted living facility care
Chiropractic care
Custodial care
Elevators or chair lifts
Exercise equipment or programs
Long-term care
Nursing homes
Weight loss products

Please view the No Government Pay Procedure Code List to see if a code has been determined by TRICARE to not cover.

Timely Filing Guidelines

Effective February 1st, 2010 all claims must be received in our office no later than one calendar year from the date services were provided. For inpatient services, the claim should be filed no later than one calendar year from the date of discharge.

If a claim is received before the time limit and we request more information from you to process the claim, the requested information is required no later than 90 days from the date of the original request or until the end of the filing deadline (one year from the date of service), whichever is later.

There are some exceptions to the filing deadline requirements. Below you will find the exceptions to the timely filing deadline. You may request a waiver of the timely filing requirements by providing a detailed reason for the delay in filing your claim. Keep in mind that the request for a waiver may be denied if the request does not meet the exception guidelines.

Exceptions to the claim filing deadline may be granted and are as follows:

1) Retroactive eligibility – Claims should be submitted within 180 days of the date you are notified.

2) Administrative error on TRICARE’s part.

3) Mental incompetence – This includes the inability to communicate because of a physical disability. A physician’s attestation statement is required in this case. There must be evidence that no legal guardian was appointed. If a legal guardian was appointed prior to the timely filing deadline, an exception will not be granted. The legal guardian is obligated to file the claim prior to the deadline.

4) Delay in processing by Other Health Insurance (OHI) – The claims must have been sent to the OHI prior to the TRICARE filing deadline or filed with TRICARE prior to the deadline but returned or denied for OHI information. The documentation should show that the OHI delayed processing of the claim past the TRICARE deadline, and the claim should be filed with TRICARE within 90 days from the process date of the OHI.

There is no time limit for submitting a request for an exception to the claim filing deadline before a claim has been submitted. However, after a claim has been submitted and an exception to the claims filing deadline is granted, TRICARE will only consider benefits for those services or supplies received during the six years immediately preceding the receipt of the request. Services or supplies claimed for more than six years preceding the receipt of the request shall be denied.

For more information, please refer to the TRICARE Operations Manual.

TRICARE NTAP Applications

How do I get a TRICARE NTAP application form?

Please see the Forms page to download the TRICARE NTAP Application. Fill out the form completely and submit via fax at 608-301-3226. Be sure to include all supporting documentation as requested in the application.

What is a TRICARE NTAP?

A TRICARE NTAP are for TRICARE covered services and supplies for which Medicare has not established an NTAP adjustment.

What are the requirements a TRICARE NTAP?

The technology must:

Be covered under current TRICARE policy
Substantially improves the diagnosis or treatment of a particular condition; improves a diagnosis or treatment of a specific subpopulation
Treat a severe, disabling, or fatal condition.
Be sufficiently new upon submission
Typically provided to patients aged 64 and younger, or for the treatment of a condition that primarily affects patients aged 64 and younger.
Not been previously reviewed by CMS for an NTAP, or rejected solely on the basis of the technology not being used to treat the Medicare beneficiary population

When is my TRICARE NTAP application due?

All applications with supporting details must be received no later than July 8 of the preceding fiscal year for a TRICARE NTAP to be considered.

Therefore, for example, if you would like your technology to be considered for Fiscal Year 2025 (beginning October 1, 2024), your application must be submitted by July 8, 2024.

Cancer and Children's Hospital

Effective October 1, 2023, Cancer and Children’s Hospitals will no longer be paid using the blended rate for hospital outpatient radiology claims. Instead, they will be subject to the OPPS. Blended rate materials will remain available for at least three years on the DHA website for dates prior to October 1, 2023, at https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement/Blend-Rate-Method-for-Radiology-for-Cancer-and-Childrens-Hospitals. For dates of service on or after October 1, 2023, where Medicare has excluded a radiology service from OPPS (i.e., applies a status indicator of A, or subsequent similar status indicator), or where TRICARE covers a radiology service that Medicare does not, and the service is not assigned a status indicator or APC, payment shall be made on the basis of CMAC pricing methodology.

Freestanding Ambulatory Surgery Centers

Effective for service dates on or after October 1, 2023, TRICARE is adopting the Medicare ASC reimbursement system including their ASC fee schedule rules, payment rates, payment indicators, list of covered procedures and ancillary services, and wage indices. Payment rate will only apply to facility charges for ambulatory surgery in an FASC, except for Current Procedural Terminology (CPT) code 41899 and certain dental procedures.

The facility rate includes nursing and technician services; use of the facility; drugs, biologicals, and radiology services, for which separate payment is not allowed under OPPS; surgical dressings, splints, casts and equipment directly related to provision of the surgical procedure; materials for anesthesia; Intraocular Lenses (IOLs); and administrative, recordkeeping and housekeeping items and services.

The facility rate does not include items such as physicians’ fees (or fees of other professional providers authorized to render the services and to bill independently for them); certain laboratory, X-rays or diagnostic procedures for which separate payment is allowed under OPPS; orphan drugs; prosthetic devices (except IOLs); corneal acquisition tissue; brachytherapy services; certain implantable devices with pass-through status under OPPS; ambulance services; leg, arm, and back braces; artificial limbs; and Durable Medical Equipment (DME) for use in the patient’s home.

For awareness this is what is currently posted on DHA’s website:

Effective Oct. 1, 2023, the Defense Health Agency has adopted Medicare's payment system for the Reimbursement of Ambulatory Surgery Centers. The rates on this page apply to services rendered before this date. For more information, visit the TRICARE Reimbursement Manual, Chapter 9, reference the final rule at 88 FR 19844 or contact your managed care support contractor.

End Stage Renal Disease Facilities

· Freestanding ESRD facilities reimbursement methodology has changes as of July 3, 2023.

· Per session rates for treatment days 1-120 is calculated using the current Medicare base rate multiplied by the current Medicare adjustment factor applied to individuals aged 60-69 and further multiplied by the current Medicare adjustment factor for the date of onset.

· Per session rate for treatment days 121 and beyond is a flat, per-session rate is calculated using the current Medicare base rate, multiplied by the Medicare adjustment factor applied to individuals aged 60-69.

· Per session rates will be adjusted by the ESRD facilities wage index applied to the labor portion through posted rates on Centers for Medicare and Medicaid Services (CMS) ESRD Payment website for each calendar year.

· A maximum of three session per week will be allowed, unless there is medical justification for addition treatments.

· Dialysis Training will be eligible for an add-on payment to the per session rate for treatment days 121 and after, when billed with appropriate condition or revenue codes.

· Dialysis provided in the home have payment limited to the hemodialysis-equivalent of three sessions per week, regardless of the number of treatments performed each day. The daily rate for in home dialysis is the weekly rate divided by seven.

· Freestanding ESRD facilities shall bill on the CMS 1450 UB-04 claim form with Type Of Bill (TOB) 72X and applicable Current Procedural Terminology (CPT) procedure codes.

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