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TRICARE rates

View CMAC rates

Fee schedule updates

CAH and SCH CCR FY2017 rates are available.

TRICARE uses the CAH and SCH CCR rates to pay claims filed for Critical Access Hospitals and

Sole Community Hospitals using Cost to Charge Ratio Data as outlined in the TRICARE Reimbursement Manual/Chapters 14 & 15.

TRICARE updates the CAH and SCH rates on an annual basis.  The CAH rates are effective December 1st and SCH rates are effective January 1st. 

Ambulatory Surgical Center FY2017 rates are available.

TRICARE uses the Ambulatory Surgical Center rates to pay claims filed for procedures that qualify to be performed in a free-standing facility.

FY 2017 Ambulatory Surgical Center rates can be found here.

TRICARE updates the Ambulatory Surgical Center rates on an annual basis and the expected implementation date is November 1, 2016.

Analysis on the Ambulatory Surgical Center rates shows an estimated 3.28% increase in reimbursement for FY2017

2017 DRG rates are available.

TRICARE uses the Diagnosis Related Grouper (DRG) rates to pay claims filed for specific Inpatient related services.

The 2017 DRG Rates can be found here.

TRICARE updates the DRG rates annually. The 2017 update was received on September 27, 2016 with an effective date of October 1, 2016. Inpatient claims with admission dates of service on or after October 1, 2017 will defer while the annual DRG rate updates are fully implemented.

The DRG rates are calculated by taking the assigned weight of the DRG and multiplying it by the Adjusted Standardized Wage Amount (ASA). Both the weights for each of the 825 DRGs have been updated as well as the ASA. Analysis on the weights shows an increase of less than 1% and analysis on the ASA shows an increase of 3.31%. DRG rates can also be adjusted by the Arithmetic or Geometric Length of Stay variable or the Short Stay variable depending on the scenario billed. The TRICARE Reimbursement Policy explains the use of the variables in Chapter 6, Section 8. All of these variables have been updated as well with a 1% decrease to both Arithmetic Length of Stay and Geometric Length of Stay and a 3% decrease to Short Stay Threshold.


DMEPOS and DMEPEN Fee Schedules are available.

TRICARE uses the DMEPOS and DMEPEN Fee Schedules to pay claims filed for DME related services.

2016 DMEPOS and DMEPEN Fee Schedules can be found at: DMEPOS Fee Schedule - Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) updates the DMEPOS and DMEPEN fee schedule on an quarterly basis for Rural and NonRural rates. The updated information for the 4th quarter of 2016 was comprised of modifications to rural zip codes only. There were no updates to the reimbursement rates.

Outpatient Prospective Payment System (OPPS) rates are available.

TRICARE uses the Outpatient Prospective Payment System (OPPS) to pay claims filed for hospital-based outpatient services.

2016 Tricare OPPS rates can be found here.

TRICARE OPPS is updated on a quarterly basis. The updated information for the 4th quarter of 2016 effective October 1, 2016. This update includes new ICD-10 codes for 2017. Outpatient claims will begin deferring on October 1st related to the new ICD-10 codes.

Analysis on the 2016 APC rate file schedule shows no significant change in reimbursement except for the codes listed below:

Code

Name

Old rate

New rate

Rate difference

Rate difference percentage

09044

Ibutilide fumarate injection

$109.03

$264.44

$155.41

142.54%

09478

Injection, sebelipase alfa

$0.00

$530.00

$530.00

100.00%

09480

Injection, trabectedin

$0.00

$280.57

$280.57

100.00%

09476

Injection, daratumumab

$0.00

$46.43

$46.43

100.00%

09479

Instill, ciprofloxacin otic

$0.00

$30.02

$30.02

100.00%

01761

Rolapitant, oral, 1mg

$0.00

$12.62

$12.62

100.00%

09477

Injection, elotuzumab

$0.00

$6.25

$6.25

100.00%

09122

Triptorelin pamoate

$234.96

$392.06

$157.10

66.86%

00827

Floxuridine injection

$47.45

$16.28

($31.17)

65.55% Decrease

00832

Idarubicin hcl injection

$36.95

$25.97

($10.98)

29.72% Decrease