Provider Handbook

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The TRICARE Outpatient Prospective Payment System (OPPS) reimbursement methodology is scheduled to be implemented for claims in the fall of 2007. The implementation date may be impacted by legislation or other policy changes. This policy is mandatory for the reimbursement of services provided either by network or non-network providers. However, alternative network reimbursement methodologies are permitted when approved by TRICARE Management Activity (TMA) and specifically included in the network provider agreement.

TRICARE OPPS applies to all hospitals participating in the Medicare program and hospital-based partial hospitalization programs subject to TRICARE authorization requirements. TRICARE OPPS also applies to hospitals or distinct parts of hospitals that are excluded from the inpatient Diagnostic Related Group Based Payment System, to the extent that the hospital or distinct part furnishes outpatient services (e.g., Sole Community Hospitals).

Several organizations, as defined by TRICARE policy, are exempt from OPPS:
 

• Indian Health Service hospitals that provide outpatient services
• Certain hospitals in Maryland that qualify for payment under the state’s cost containment waiver
• Critical access hospitals
• Hospitals located outside one of the 50 states, Washington, D.C., and Puerto Rico
  Specialty care providers including:
  • Cancer and children’s hospitals
  • Freestanding ambulatory surgery centers
  • Freestanding partial hospitalization programs
  • Freestanding end-stage renal disease facilities
  • Comprehensive outpatient rehabilitation facilities
  • HHAs
  • Hospice programs
  • Community mental health centers
  • Other corporate services providers (e.g., freestanding cardiac catheterization and sleep disorder diagnostic centers)
  • Freestanding birthing centers
  • Department of Veterans Affairs hospitals

• Hospital-based (PHPs) are subject to OPPS reimbursements. PHP claims require the combination of 912/913 revenue codes with the corresponding HCPCS H0035/H0037. The total payment for the same date of service is limited to a full-day PHP payment. PHP claims require TOB 13x, MH dx, and condition code 41.
   
• The total amount payable for psychiatric services furnished in a hospital outpatient department (not under the partial hospitalization program) for an individual for one day will be limited to the APC per diem payment amount for full-day partial hospitalization. (See the TRICARE Reimbursement Manual, Chapter 13, Section 2, p 10.)
   
• Multiple surgery and bilateral procedure discounts for non-OPPS claims (that is claims submitted by excluded providers including professional providers) are subject to OPPS discounting.
   
• Hospital-based outpatient facilities must submit claims on UB-04 with TOB 13x.
  ASC pricing does not apply to hospital-based outpatient facilities.
   
• If providers share the same UPIN and one provider has an IDME factor, then that IDME factor applies to all providers that share that UPIN.

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