CHAMPUS and TRICARE Allowed Charges
CHAMPUS Maximum Allowable Charge
The 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
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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:
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 previous years’ CMAC files 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 previous years’ 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 term “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).
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.
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