Skilled Nursing Facility Pricing
TRICARE pays skilled nursing facilities (SNFs) using the Medicare PPS and consolidated billing. SNF PPS rates cover all routine, ancillary, and capital costs of covered SNF services. SNFs are required to perform resident assessments using the Minimum Data Set. SNF admissions require authorizations when TRICARE is the primary payer.
SNF admissions for children under age 10 and CAH swing beds are exempt from SNF PPS and are reimbursed based on DRG or contracted rates. For information about SNF PPS, refer to the TRICARE Reimbursement Manual. Home Health Agency Pricing
TRICARE pays Medicare-certified home health agencies (HHAs) using a PPS modeled on Medicare’s plan. Medicare-certified billing is handled in 60-day-care episodes, allowing HHAs to receive two payments of 60 percent and 40 percent, respectively, per 60-day cycle. This two-part payment process is repeated with every new cycle, following the patient’s initial 60 days of home health care.
All home health services require prior authorization from Humana Military and must be renewed every 60 days. To receive private-duty nursing or additional nursing services/shift nursing, the TRICARE beneficiary may be enrolled in an alternative TMA-approved special program, an a case manager must manage his or her progress.
Tips for Filing a Request for Anticipated Payment
To file a request for anticipated payment (RAP):
The bill type in Form Locator (FL) 4 of the UB-04 is always 322 or 332. The “To” date and the “From” date in FL 6 must be the same and must match the date in FL 45. FL 39 must contain code 61 and the Core-Based Statistical Area code of the beneficiary’s residence address. There must be only one line on the RAP, and it must contain revenue code 023 and 0 dollars. On this line, FL 44 must contain the Health Insurance PPS code. The quantity in FL 46 must be 0 or 1. FL 63 must contain the authorization code assigned by the Outcome Assessment Information Set. Note: This is not Humana Military’s prior authorization number.
Tips for a Final Claim
Network home health care providers must submit TRICARE claims electronically. The bill type in FL 4 must always be 329 or 339. In addition to the blocks noted for the RAP above, each actual service performed with the appropriate revenue code must be listed on the claim form lines. The claim must contain a minimum of five lines to be processed as a final RAP. The dates in FL 6 must be a range from the first day of the episode, plus 59 days. Dates on all of the lines must fall between the dates in FL 6.
Exceptions
Beneficiaries enrolled in the Custodial Care Transition Program (CCTP) are exempt from the new claim-filing rules and providers treating them may continue fee-for-service billing. For details about beneficiaries grandfathered under the CCTP, refer to the TRICARE Policy Manual, Chapter 8, Section 15.1. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Pricing
Durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) prices are established by using the Medicare fee schedules, reasonable charges, state prevailing rates, or average wholesale pricing (AWP). Most durable medical equipment (DME) payments are based on the fee schedule established for each DMEPOS item by state. The services and/or supplies are coded using CMS Healthcare Common Procedure Coding System (HCPCS) Level II codes that begin with the letters:
- A (medical and surgical supplies)
- B (enteral and parenteral therapy)
- E (DME)
- K (temporary codes)
- L (orthotics and prosthetic procedures)
- V (vision services)
Inclusion or exclusion of a fee schedule amount for an item or service does not imply TRICARE coverage or non-coverage.
DMEPOS pricing information is available at TRICARE's Web site.
Home Infusion Drug Pricing
Home infusion drugs are those drugs (including chemotherapy drugs) that cannot be taken orally and are administered in the home by other means: intramuscularly, subcutaneously, intravenously, or infused through a piece of DME. DME verification is not required.
Home infusion drugs are reimbursed the lesser of the billed amount or 95 percent of the AWP, as retrieved from the National Drug Data File (formerly the National Drug Blue Book). Home infusion drugs must be billed using an appropriate “J” code along with a specific National Drug Code (NDC) for pricing.
Claims for home infusion will be identified by the place of service and the CMS HCPCS National Level II Medicare codes along with the specific NDC number of the administered drug. Modifiers
Industry-standard modifiers are often used with procedure codes to clarify the circumstances under which medical services were performed. Modifiers allow the reporting physician to indicate that a service or procedure has been altered by some specific circumstance but has not been changed in definition or code. Modifiers may be used by the physician to indicate one of the following:
- A service or procedure has both a professional and technical component.
- A service or procedure was performed by more than one physician and/or in more than one location.
- A service or procedure has been increased or reduced.
- Only part of a service, an adjunctive service, or a bilateral service was performed.
- A service or procedure was provided more than once.
- Unusual events occurred during the service.
- A procedure was terminated prior to completion.
Providers should use applicable modifiers that fit the description of the service, and the claim will be processed accordingly. The CPT and HCPCS publications contain lists of modifiers available for describing services.
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