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TRICARE CHAMPUS Maximum Allowable Charge (CMAC) changes for 2005 are effective for services rendered on or after April 1, 2005. The most significant changes to the CMAC include payments based on “site of services” as TRICARE will now implement similar payment methodologies utilized by Medicare.
Although payment based on site of service is a new concept to TRICARE, it is already used by Medicare to distinguish between services rendered in a facility setting as opposed to a non-facility setting.
Previous CMAC pricing by provider class will be superseded by the following four categories:
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 hospitals (both inpatient and outpatient where the hospital is generating a revenue bill, e.g., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities, ambulatory surgical centers, etc.
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 non-facility,including provider offices, home settings, and all other non-facility settings.
Category 3—Services, of all other providers not found in category 1, provided in a facility, including hospitals (both inpatient and outpatient where the hospital is generating a revenue bill, e.g., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities, ambulatory surgical centers, etc.
Category 4—Services of all other providers, not found in category 2, provided in a non-facility, including provider offices, home settings, and all other non-facility settings.
Note: Services and procedure codes not affected by payment based on site of service include anesthesia services, laboratory services, component pricing services, such as radiology and “J” codes.
Access the CMAC rates portion of the TRICARE Web site at www.tricare.osd.mil/cmac/ to determine the new CMAC rates based on site of service.
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