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OPPS Updates and Reminders (Article 4) |
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In the coming months, TRICARE will begin using the Outpatient Prospective Payment System (OPPS) to pay claims filed for hospital outpatient services.
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Because the Interim Final Rule for TRICARE OPPS is still pending approval, no date has been set for OPPS implementation.
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TRICARE OPPS is not a prepayment system, as its name may suggest, but a payment methodology giving hospitals and providers an understanding of how their claims will be processed before they are submitted. It is an ambulatory patient
classification (APC) system for covered hospitalbased outpatient services, and it establishes standardized national payment rates for geographic wage differences.
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Under OPPS, reimbursable services are assigned an APC, a predetermined number under which there may be
one or more CPT/HCPCS codes.
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Criteria for grouping procedures and services under the APCs include:
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- Similarities in the amounts and types of resources used
- Similarity of the organ system or etiology
- Number of providers offering the services (i.e., the degree of provider concentration associated with the APC’s services or individual services that comprise the APC)
- How often (and widely) a particular service is offered
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TRICARE OPPS uses the Medicare APCs whenever possible. However, when there is no Medicare designation, a TRICARE-specific APC group and rate are created. TRICARE-specific APC’s begin with the letter “T.”
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Providers who are subject to TRICARE OPPS Include:
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- All hospitals participating in the Medicare program, with certain exclusions (listed below)
- Hospital-based partial hospitalization programs subject to TRICARE authorization requirements under 32 CFR
199.6(b)(4)(xii)
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The Providers excluded from TRICARE OPPS are:
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- Outpatient services provided by hospitals of the Indian Health Service
- Certain hospitals in Maryland that qualify for payment under the state’s cost containment waiver
- Critical access hospitals ( www.tricare.mil/opps)
- Hospitals located outside the United States and Puerto Rico
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All hospital outpatient departments are subject to OPPS unless specifically excluded by TRICARE.
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For more information on TRICARE OPPS, the following TRICARE and Centers for Medicare and Medicaid Services Web sites are available:
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- TRICARE OPPS Resources:
- Centers for Medicare and Medicaid Services:
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Created: July 9, 2007
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