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TRICARE Outpatient Prospective Payment System (OPPS) |
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Legislative Mandate |
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Under 10 U.S.C. 1079(h) and 1079(j)(2), TRICARE was mandated to adopt Medicare’s reimbursement rules when practicable. Based on these statutory provisions, TRICARE will adopt Medicare’s prospective payment system for reimbursement of hospital outpatient services. |
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Overview
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Under the OPPS, hospital outpatient services are paid on a rate-per-service basis that varies according to the Ambulatory Payment Classification (APC) group to which the services are assigned. Group services identified by Health Care Procedure Coding System (HCPCS) codes and descriptors within APC groups are the basis for setting payment rates under the hospital OPPS. To receive TRICARE reimbursement under the OPPS, providers must follow all Medicare specific coding requirements, except in those instances where TMA develops specific APCs for those services that are unique to the TRICARE beneficiary population.
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Differences between TRICARE and Medicare OPPS |
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While the TRICARE OPPS is modeled after the Medicare OPPS, there are some differences in the two systems, such as covered benefits and copayments. The TRICARE Outpatient Code Editor will reflect these differences allowing payment for those services that are covered under TRICARE, but not under Medicare and vice versa. In addition TRICARE will retain its current hospital outpatient deductible, cost sharing/copayment amounts and catastrophic loss protection under its OPPS. Following is a summary of the notable differences between TRICARE and Medicare’s OPPS.
Read more ... |
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For More Information
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OPPS FAQs
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TMA Rates and Reimbursements for OPPS |
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TRICARE Provider News
February 2007: "Introducing the Outpatient Prospective Payment System"
March 2007: "TRICARE OPPS: What's Included and What's Not:"
June 2007: "OPPS Implementation Date Change"
August 2007: "OPPS Updates and Reminders"
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