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CHAMPUS and TRICARE Allowed Charges
CHAMPUS Maximum Allowable Charge
The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) maximum allowable charge (CMAC) is the maximum amount TRICARE will reimburse for nationally established procedure coding (i.e., codes for institutional or professional services). Humana Military Healthcare Services, Inc. (Humana Military), will retain and maintain previous years’ CMAC files for historical purposes. Updated CMAC rates based on site of service are available on the TRICARE CMAC web site. Periodic CMAC changes apply to both network and non-network providers.
Site-of-Service Pricing
TRICARE CMAC changes vary at the discretion of the TRICARE Management Activity (TMA). The categories in Figure 9.1 represent the four classes of providers used for reimbursement.
CMAC Procedure Pricing Calculator
To visit the CMAC calculator, follow the online prompts. For CMAC rates, use the applicable Current Procedural Terminology (CPT®) code.
Questions about using this application can be sent to Webmaster-CMAC@tma.osd.mil. Figure 9.1 TRICARE Provider Categories
| Category |
Provider Type |
Facility Type |
| Category 1 |
Medical doctors (MDs), doctors of osteopathic medicine (DOs), optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, audiologists, and applicable outpatient hospital services |
Services provided in a facility1 |
| Category 2 |
MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, audiologists, and applicable outpatient hospital services |
Services provided in a non-facility2 |
| Category 3 |
All provider types NOT found in Category 1 |
Facility setting |
| Category 4 |
All provider types NOT found in Category 2 |
Non-facility setting |
1 A facility includes the following: ambulances, ambulatory surgery centers, community mental health centers, hospices, hospitals (both inpatient and outpatient where the hospital generates a revenue bill; i.e., revenue code 510), military treatment facilities, psychiatric facilities, residential treatment centers, skilled nursing facilities.
2 A non-facility includes the following: home settings, provider offices, and other non-facility settings.TRICARE-Allowable Charge
The TRICARE-allowable charge is the maximum amount TRICARE will authorize for medical and other services furnished in an inpatient or outpatient setting.
For example:
If the TRICARE-allowable charge for a service is $90 and the billed charge is $50, the TRICARE-allowable charge becomes $50 (the lower of the two charges). If the TRICARE-allowable charge for a service is $90, and the billed charge is $100, TRICARE will allow $90 (the lower of the two charges). In the case of inpatient hospital payments, the specific hospital reimbursement method applies (e.g., diagnosis-related group [DRG] rate is the TRICARE-allowable charge regardless of the billed amount, unless otherwise stated in the provider’s contract.) In the case of outpatient hospital claims subject to TRICARE outpatient prospective payment system (OPPS), services will be subject to OPPS ambulatory payment classifications (APCs), where applicable.
State Prevailing Rates
State prevailing rates are established for codes that have no current available CMAC pricing. Prevailing rates are those charges 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. In lieu of a specific exception, prevailing profiles are developed on:
- A statewide basis (Localities within states are not used, nor are prevailing profiles developed for any area larger than individual states.)
- A non-specialty basis
Prevailing profiles are developed using a minimum of eight claims submitted for reimbursement to TRICARE. All actual charges billed for the service are put in ascending order, and the lowest charge (in the array) that is high enough to include 80 percent of the cumulative charges (number of claims billed) becomes the prevailing charge. For more details, refer to the TRICARE Reimbursement Manual, Chapter 5, Section 1.
For codes with prevailing rates during the period January–October 1991, the prevailing rates were frozen at the 1990 level, consistent with Public Law 101–511, Section 8012. Additional new codes have been established by the American Medical Association® that have no current available CMAC pricing. For more details, refer to the TRICARE Reimbursement Manual, Chapter 5, Section 1.
If TRICARE does not receive eight claims for a particular procedure, TRICARE will determine the prevailing rate by using information about the volume of business done by various providers or suppliers within the TRICARE South Region or through available price lists and supply catalogs.
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