Ambulatory surgery facility charges fall into one of 11 TRICARE grouper rates . TRICARE payment rates established under this system apply only to the facility charges for ambulatory surgery.
Freestanding ambulatory surgery center (ASC) claims may be submitted for TRICARE-approved ASC procedures on a UB-92. Hospital Outpatient ASC charges may be submitted on the 837 transaction (electronic version of the CMS-1500) and the surgery grouper (SG) modifier should be indicated on the form.
All procedures are approved on the baiss of medical necessity.
For additional information, ambulatory surgery providers may view reimbursements and grouper assignments, or they may contact their local Humana Military Provider Relations representative.
When all procedures are performed during the same operative session, multiple ambulatory surgeries are processed according to multiple surgery guidelines. Reimbursement is based upon the sum of the following:
One hundred percent of the payment amount for the surgical procedure with the highest ASC payment grouper amount
Fifty percent of the ASC grouper payment amount for each of the other surgical procedures performed during the same session
No reimbursement is made for incidental procedures performed during the same operative session in which other covered surgical procedures were performed. In some instances of multiple ambulatory surgeries, one procedure is on the approved list and one is not. PGBA, LLC (PGBA) (Humana Military’s claims processing partner) processes the charges for the procedure on the approved list under the ambulatory surgery guidelines. The procedure on the approved list is reimbursed as described previously. Facility charges for procedures that are not on the approved list are reimbursed at the TRICARE-allowable charge, billed charge, or contracted rate appropriate for the procedure performed.
Visit TRICARE's web site to find ambulatory surgery rates. Here you can search for rates by ZIP code, city, or state. You can also download ambulatory surgery rate data.
