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Provider Handbook
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Previous Section Table of Contents Next Page
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TRICARE
Reimbursement
Methodologies
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Reimbursement Limitations
CHAMPUS Maximum Allowable Charge
Site of Service Pricing Changes |
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Reimbursement rates and methodologies are subject to change per Department of Defense (DoD) guidelines. See the TRICARE Reimbursement Manual for more information. |
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Reimbursement Limitations |
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Payments made to network providers for medical services to TRICARE beneficiaries shall not exceed 100 percent of the TRICARE allowable charges. |
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CHAMPUS Maximum Allowable Charge |
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The CHAMPUS maximum allowable charge (CMAC) is the amount TRICARE will cover for nationally established fees. CMAC is the TRICARE allowable charge for covered services when appropriately applied to services priced under CMAC.
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Site of Service Pricing Changes |
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The following four categories represent the four classes of providers used for reimbursement.
Category 1: Services of M.D.s, D.O.s, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a facility, including:
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- Ambulances
- Ambulatory surgical centers
- Community mental health centers
- Hospices
- Hospitals (both inpatient and outpatient where the hospital is generating a revenue bill; i.e., revenue code 510)
- Military treatment facilities (MTFs)
- Psychiatric facilities
- Residential treatment centers
- Skilled nursing facilities (SNFs)
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Category 2: Services of M.D.s, D.O.s, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a non-facility, including:
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- Home settings
- Other non-facility settings
- Provider offices
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Category 3: Services of all other providers not found in Category 1 provided in a facility.
Category 4: Services of all other providers not found in Category 2 provided in a non-facility.
Updated CMAC rates based on site of service are available on the TRICARE Web site. Annual CMAC changes apply both to network and non-network providers.
Humana Military will retain and maintain previous years’ CMAC files for historical purposes.
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CMAC Procedure Pricing Calculator |
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To use the CMAC calculator, go to the TRICARE Web site. Accept the “End User Point and Click Agreement.” Then, click on “CMAC Procedural Pricing.” You’ll see a Web form on the screen. Just fill in the blanks and click “Search.” The procedure pricing is based on the locality code. You can select a locality code for the geographic region you are querying, or you may look up locality codes by selecting a state, entering a catchment area code, or entering a ZIP code.
Questions about using this application can be sent to Webmaster_CMAC@tma.mil.
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