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The TRICARE CHAMPUS maximum allowable charge, or “CMAC,” pricing is updated annually after Medicare pricing is established.
CMAC is the maximum amount TRICARE will cover for professional services (e.g., physicians, nurse practitioners, physician assistants, anesthesiologists, etc.). CMAC pricing varies by provider location, and there are 90 localities based on ZIP code.
To verify CMAC rates in your area, visit TRICARE's Web site. After accepting the end-user agreement, click on “CMAC Procedure Pricing.” The procedure pricing is calculated based on the “locality code.” You can select a locality code from a drop-down menu for the geographic region you are querying, or you can look up locality codes by selecting a state, entering a catchment area code or entering a ZIP code.
For more information, call 1-800-444-5445.
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TRICARE requires all network providers to file claims electronically.
For assistance with any issues related to electronic media claims (EMC) submission for the TRICARE South Region, you can contact the PGBA EMC Help Desk at 1-800-325-5920, option 2.
You can also visit PGBA's Web site for more information regarding electronic claims submission.
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Consult reports are required to be returned to the primary care manager (PCM) or initiating provider within 10 working days of the patient encounter. For routine specialty referrals for initial office visits, all outpatient services and inpatient services, you must provide complete and legible documentation for these reports to be accurate and useful.
Returning consult reports, operative reports and discharge summaries to the initiating provider is important for timely follow up and continuity of care. Please be responsive to the request when asked to return a consult report for TRICARE beneficiaries.
Providers who treat TRICARE beneficiaries coming from the local military treatment facility may receive a faxed reminder to return a consult report for a recent visit/service. Your office should return the consult report, operative report or discharge summary requested and use the designated fax reminder as the cover sheet. Please use the fax number listed in the upper right corner of the reminder page. This fax number is shown only on the reminder fax to providers for each beneficiary consult return request. This is to avoid having providers send documentation on all other TRICARE beneficiaries.
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