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 amount TRICARE will reimburse for nationally established procedure coding. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.
Site-of-Service Pricing Categories
The following four categories represent the four classes of providers used for reimbursement of most services under CMAC.
Category 1: Services of M.D.s, D.O.s, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, audiologists, and applicable outpatient hospital services provided in a facility, including:
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Ambulances
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Ambulatory surgery centers (ASCs)
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Community behavioral health centers
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Hospices
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Hospitals
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Military treatment facilities (MTFs)
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Psychiatric facilities
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Residential treatment centers
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Skilled nursing facilities (SNFs)
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 a non-facility, including:
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Home settings
- Provider offices
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Other non-facility settings
Category 3: Services of all other providers not found in Category 1 provided in a facility.
Category 4: Services of all other providers not found in Category 2 provided in a non-facility.
Humana Military Healthcare Services, Inc. (Humana Military) will retain and maintain CMAC files from previous years for historical purposes. Updated CMAC rates based on site of service are available on the TRICARE Web Site. Periodic CMAC changes apply to both network and non-network providers.
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.
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:
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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).
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If the billed charge is $100, TRICARE will allow $90 (the lower of the two charges).
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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.
Per TRICARE policy, for codes with prevailing rates during the period January–October 1991, the prevailing rates were frozen at the 1990 level, consistent with Public Law (P.L.) 101–511, Section 8012. Additional new codes have been established by the American Medical Association that have no current available CMAC pricing. Those codes have not been frozen.
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