Outpatient Prospective Payment System
TRICARE OPPS was implemented on May 1, 2009, to pay claims filed for hospital outpatient services. TRICARE OPPS is mandatory for both network and non-network providers and applies to all hospitals participating in the Medicare program, with some exceptions (e.g., CAHs, cancer hospitals, and children’s hospitals). TRICARE OPPS also applies to hospital-based partial hospitalization programs (PHPs) subject to TRICARE’s prior authorization requirements, and hospitals (or distinct parts thereof) that are excluded from the inpatient DRG-based payment system, to the extent the hospital (or distinct part thereof) furnishes outpatient services.
Several organizations, as defined by TRICARE policy, are exempt from OPPS:
- CAHs
- Certain hospitals in Maryland that qualify for payment under the state’s cost containment waiver
- Hospitals located outside one of the 50 United States; Washington, D.C.; and Puerto Rico
- Indian Health Service hospitals that provide outpatient services
- Specialty care providers, including:
- Cancer and children’s hospitals
- Community mental health centers
- Comprehensive outpatient rehabilitation facilities
- Department of Veterans Affairs hospitals
- Freestanding ASCs
- Freestanding birthing centers
- Freestanding end-stage renal disease facilities
- Freestanding PHPs (psychiatric facilities and substance use disorder rehabilitation facilities [SUDRFs])
- HHAs
- Hospice programs
- Other corporate services providers (e.g., freestanding cardiac catheterization and sleep disorder diagnostic centers)
- SNFs
- Residential treatment centers
CMAC fee schedule pricing, including injectable rates on payable claim lines that are not grouped to an APC, are updated on a quarterly basis. Annual CMAC rates generally available and effective February 1 have a two-month lag under OPPS (i.e., April 1 instead of February 1).
For more information on TRICARE OPPS implementation, refer to the TRICARE Reimbursement Manual, Chapter 13, visit TRICARE's OPPS web page, or contact Humana Military at 1-800-444-5445.
Temporary Transitional Payment Adjustments
Temporary Transitional Payment Adjustments (TTPAs) are in place for all hospitals, both network and non-network, in order to buffer the initial decline in payments upon implementation of TRICARE OPPS. For network hospitals, the TTPAs cover a four-year period. The four-year transition sets higher payment percentages for the 10 APC codes for emergency room (ER) and hospital clinic visits (APC codes 604–609 and 613–616), with reductions in each transition year.
For non-network hospitals, the TTPAs cover a three-year period, with reductions in each transition year.
Figure 9.3 shows the TTPA percentages for APC codes 604–609 and 613–616 during the four-year network hospital, and three-year non-network hospital, transition periods. Figure 9.3 TTPA Percentages for APC Codes 604–609 and 613–616
|
Network1
|
Non-network2
|
Transition
Period
|
ER
|
Hospital
Clinic
|
ER
|
Hospital
Clinic
|
| Year 1 |
200% |
175% |
140% |
140% |
| Year 2 |
175% |
150% |
125% |
125% |
| Year 3 |
150% |
130% |
110% |
110% |
| Year 4 |
130% |
115% |
100% |
100% |
| Year 5 |
100% |
100% |
100% |
100% |
1. The transition period for network hospitals is four years. In year 5, TRICARE’s payment level will be the same as Medicare’s (i.e., 100%).
2. The transition period for non-network hospitals is three years. In year 4, TRICARE’s payment level will be the same as Medicare’s (i.e., 100%).Temporary Military Contingency Payment Adjustments
Network hospitals that have received OPPS payments of $1.5 million or more for care provided to ADSMs and active duty family members during an OPPS year (May 1 through April 30) will be given a Temporary Military Contingency Payment Adjustment (TMCPA). Hospitals that qualify for a TMCPA will receive a 20 percent increase in the total OPPS payments for the initial year of OPPS (May 1, 2009 through April 30, 2010). Subsequent adjustments will be reduced by 5 percent each year until the OPPS payment levels are reached in year five (i.e., 15 percent year two, 10 percent year three, and 5 percent year four).
Filing Claims for PHP Charges
Effective May 1, 2009, the TRICARE OPPS pays claims filed for hospital outpatient services, including hospital-based PHPs (psychiatric and SUDRFs) subject to TRICARE’s prior authorization requirements. The outpatient code editor logic requires that hospital-based PHPs provide a minimum of three units of service per day in order to receive PHP payment. For calendar year 2009, payments were denied for days when fewer than three units of therapeutic services were provided.
TRICARE has adopted Medicare’s PHP reimbursement methodology for hospital-based PHPs. There are two separate APC payment rates under this reimbursement methodology:
- APC 0172: For days with three services
- APC 0173: For days with four or more services
Additionally, TRICARE allows physicians, clinical psychologists, clinical nurse specialists, NPs, and PAs to bill separately for their professional services delivered in a PHP. The only professional services that are included in the PHP per-diem payment are those furnished by clinical social workers, occupational therapists, and alcohol and addiction counselors.
The claim must include a mental health diagnosis and an authorization on file for each day of service. Since there is no HCPCS code that specifies a partial hospitalization related service, partial hospitalizations are identified by means of a particular bill type and condition code.
For more information on how OPPS affects TRICARE PHPs and for a complete listing of applicable revenue and HCPCS codes, refer to Chapter 13, Section 2 of the TRICARE Reimbursement Manual or contact Humana Military at 1-800-444-5445.
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