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Provider Handbook
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TRICARE-Allowable Charge
National Conversion Factors
State Prevailing Rates
Anesthesia Rates
Anesthesia Claims and Reimbursement |
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TRICARE-Allowable Charge |
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The term “TRICARE-allowable charge” is the maximum amount TRICARE will authorize for medical and other services furnished in an inpatient or outpatient setting. The TRICARE-allowable charge is normally the lower of the actual billed charge and the TRICARE-allowable charge. For example:
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- If the TRICARE-allowable charge for a service is $90 and the billed charge is $50, the TRICARE allowable charge is $50 (actual billed charge).
- If the billed charge is $100, TRICARE will pay $90 (the TRICARE-allowable charge). In the case of inpatient hospital payments, the diagnosis-related group (DRG) is the TRICARE-allowable charge regardless of the billed amount, unless otherwise stated in the provider’s contract.
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National Conversion Factors |
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TRICARE uses the conversion factors utilized by Medicare. The formulae are not identical to the Centers for Medicare and Medicaid Services (CMS), so the final calculation result will differ slightly from that calculated by Medicare. CMAC payment levels are equal to or higher than Medicare in most cases. |
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State Prevailing Rates |
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Prevailing rates are those that fall within the range of charges most frequently used in a state for a particular procedure or service. When no fee schedule is available, a prevailing charge is developed for the state in which the service or procedure is provided. |
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Anesthesia Rates |
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TRICARE reimbursement of anesthesia services is calculated using the number of time units, the Medicare relative value units, and the anesthesia conversion factor. |
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Anesthesia Claims and Reimbursement |
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Professional anesthesia claims must be submitted on an appropriate CMS-1500 form, using current [Physician’s] Current Procedural Coding (CPT) anesthesia codes (00100–01999) and the appropriate physical status (P) modifier. The use of other optional modifiers may also be appropriate. An anesthesia claim must specify who provided the anesthesia. In cases where a portion of the anesthesia service is provided by an anesthesiologist and a nurse anesthetist performs the remainder, the claim must identify exactly which services were provided by each. It is not appropriate to include revenue codes on a professional anesthesia claim.
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