TRICARE uses the Outpatient Prospective Payment System (OPPS) to pay claims filed for hospital-based outpatient services. While the TRICARE OPPS closely mirrors Medicare’s OPPS method, there are some necessary differences to accommodate the uniqueness of the TRICARE program.
Outpatient services provided by cancer and children's hospital are subject to OPPS for service dates on or after Oct. 1, 2023. (For services prior to Oct. 1, cancer and children's hospitals are exempt from OPPS billing.) You can look up OPPS reimbursement rates at https://health.mil/rates.
We offer the following answers to frequently asked questions about this change. Find complete details in the TRICARE Reimbursement Manual (TRM), Chapter 13.
Frequently Asked Questions
Will children or cancer hospital network agreements be amended?
We do not anticipate any changes to network agreements as a result of this change.
Will facilities need to change their billing programs?
There are no additional claim form fields when billing an OPPS claim. You’ll need to bill in accordance with TRM, Chapter 13. Learn more about submitting claims on our claims submission page.
Is there still a transitional OPPS payment (TOP)?
With cancer and children’s hospitals moving to OPPS reimbursement effective Oct. 1, 2023, these facilities may be eligible for hold-harmless payments every year. Hold-harmless payments are based on cost-to-charge ratios (CCR) instead of the payment-to-cost ratio. Payments are made annually and are calculated within 180 days of the end of the OPPS year (April 1 through March 30). Claims with other primary coverage are excluded from the calculation.
You do not need to request a hold-harmless payment. DHA will calculate whether a hospital’s cost exceeded the actual payments made under OPPS. If so, the hospital will receive a payment adjustment to allow for 100% reimbursement of costs.
DHA makes this calculation by:
- Multiplying the total billed charges for OPPS services for the 12-month period by the hospital-specific outpatient CCR.
- Adding together total TRICARE payments, cost-shares, and deductibles for OPPS services, and transitional outlier payments and pass-through payments (for drugs, biologicals, and/or devices).
If the result from Step 1 is greater than Step 2, the hospital will be issued a payment equal to 100% of the result of Step 1 minus the result of Step 2.
If the result from Step 2 is greater than Step 1, no additional payment will be made.
What if outpatient services span Sept. 30, 2023 to Oct. 1, 2023?
Health Net Federal Services will separate claims that include multiple service dates spanning Sept. 30–Oct. 1, 2023. Reimbursement will be based on the policy in effect on the date of service. For emergency room encounters, observation stays, or other encounters which span multiple service dates, the date of service will be the date the service begins; for all other services related to that encounter (e.g., lab, radiology, etc.) the date of service will be when the service was rendered.
Will the blended rate for hospital outpatient radiology claims still apply?
Effective Oct. 1, 2023, cancer and children’s hospitals will no longer be paid using the blended rate for outpatient radiology claims. Instead, they will be subject to OPPS. For radiology services that Medicare excludes from OPPS, payments will be based on the CHAMPUS Maximum Allowable Charge (CMAC).
How are facilities paid General Temporary Military Contingency Payment Adjustments (GTMCPA)? Do we have to request these?
DHA may approve a GTMCPA payment for hospitals that serve a disproportionate share of active duty service members (ADSM) and active duty family members (ADFM). Please review TRM, Chapter 13 for complete details.
For cancer and children’s hospitals who meet criteria, GTMCPA payments can be up to 115% of the hospital’s costs for OPPS services. For a cancer or children’s hospital to be considered for a GTMCPA payment:
- 10% of the hospital’s revenue must have been from TRICARE for care of ADSMs/ADFMs (for the previous OPPS year of May 1 through April 30)
and
- The number of OPPS visits by ADSMs and ADFMs during that same 12-month period must have been at least 10,000.
Note: Criteria for GTMCPA payments differs for other hospital types.
Facilities must request a claims records review by DHA to be considered for a GTMCPA payment. To do this, mail or fax a request to HNFS:
Health Net Federal Services, LLC
Attn: Provider Network Management
P.O. Box 9410
Virginia Beach, VA 23450-9410
Fax: 1-844-836-5818
How do facilities determine whether patients are ADSMs or ADFMs?
You can determine a TRICARE patient’s military status by their ID card. Most ADSMs carry a Common Access Card (CAC). ADFMs carry Uniformed Services ID cards that include a “Sponsor Affiliation” field.
You also can use our Check Eligibility tool or our self-service customer service phone menu to verify sponsor status.
Learn more:
