Organ acquisition rates request update

May 31, 2024

Effective Oct. 28, 2019, TRICARE offers reimbursement for reasonable and necessary organ acquisition services and costs in support of quality organ transplant programs. Under Medicare, Certified Transplant Centers (CTC) and Organ Procurement Organizations (OPO) report these costs using the Centers for Medicare and Medicaid Services (CMS) Forms 2552 and 216. TRICARE will use the Medicare Standard Acquisition Charges (SAC) to determine reimbursement amounts.

 

Humana Military is tasked each year with surveying all hospitals that had an organ acquisition cost and providing this information to the Defense Health Agency (DHA) for the TRICARE East Region.

 

To remain compliant, providers should return the following documents before July 31, 2024:

 

Please use the form referenced above and do not submit D-4 worksheets.

 

Please note: the address submitted on the form will be used for the annual correspondence for SAC rates.

 

Failure to return this information will result in TRICARE’s use of a provider facility’s overall operation cost-to-charge ratio to reduce charges, per TRICARE Reimbursement Manual. If a facility does not have any SAC rates for the year, providers should provide an explanation.

 

Please return the required information, including any relevant point of contact to HMHSPricingMailbox@HumanaMilitary.com

  

Reference numbers can now be created for basic inquiries through automated phone system

May 17, 2024

Providers can now create reference numbers for basic inquiries on claim status, eligibility/benefits or referral/authorization status when using our automated phone system. To create a reference number, simply use your provider TIN + todays date in MM/DD/YYYY format.

 

EXAMPLE: 78599632105172024

  

Changes to Freestanding Ambulatory Surgery Centers (ASC) reimbursement effective Oct. 1

April 10, 2024

Effective for service dates on or after October 1, 2023, TRICARE policy requires claims for care rendered at freestanding Ambulatory Surgery Centers (ASC) to process using the Medicare ASC Payment System for reimbursement. See the TRICARE Reimbursement Manual (TRM) Ch. 9, Sec. 2 Ambulatory Surgical Center (ASC) Reimbursement for service on or after October 1, 2023, for additional details.

 

Freestanding ASCs that specifically service pediatric populations, and do not have a Medicare participation agreement, must be accredited by the Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC) and enter into a participation agreement with TRICARE.

 

Please see the following general guidance on claims reimbursement:

  • Freestanding ASCs that do not meet all of the above Medicare eligibility requirements are no longer eligible for reimbursement for services rendered on or after October 1, 2023.
  • For services rendered before October 1, 2023, claims will be processed using the rates found on Ambulatory Surgical Center (ASC) Payment page.
  • Claims are now releasing in phases.

 

Additionally, per TRM Ch. 1, Sec 7, facility claims should be filed on a UB-04.

 

For more information about this TRICARE policy change, visit the TRM, Ch. 9, Sec. 2

 

For more information on participating with Medicare, providers should contact the Centers for Medicare & Medicaid Services (CMS)

 

Please check back regularly as this article will be updated with the latest information.

  

Update to Sensory Integration Therapy (SIT) billing

April 10, 2024

TRICARE recently clarified that SIT, billed as CPT code 97533, is not payable separately or when billed in conjunction with other therapies. For example, SIT services provided during an otherwise covered multidisciplinary therapeutic intervention or service; during physical therapy, occupational therapy or speech therapy; or as a component of cognitive rehabilitation, are services for which TRICARE bundles payment in the payment for other related services.

 

Additionally, CPT Code 97533 will be removed from the Government No Pay list and added to the bundled services list.

 

The effective date for this change is April 26, 2024.

 

For more information, see TRICARE Policy Manual (TPM) Ch. 7:

  

Change Healthcare third party system outage

March 26, 2024

On February 21, 2024, Humana Military was alerted about a system outage affecting third-party vendor, Change Healthcare. Although Humana Military was not directly affected by this outage, many of our providers have reported issues. For urgent referral and authorization submissions that can't be processed through self-service, please contact us at (800) 444-5445. For routine requests, please allow two-business-day waiting period to check if service is restored before resorting to fax. Please note, due to contractual obligations, Humana Military is unable to suspend audits or waive referrals and authorizations at this time.

 

Due to this outage, providers may choose from the following options to submit claims:

  1. Pick an alternate clearinghouse or vendor for electronic claims
  2. Use self-service, as long as the provider’s account is set up for electronic transactions
  3. Submit paper claims, using either CMS1500 or UB04, depending on the type of the provider

Buy-and-Bill Reimbursement of Spravato

February 16, 2024

TRICARE recently updated language to clarify the billing procedures for the reimbursement of Spravato ® (esketamine) nasal spray.

 

According to the Food and Drug Administration (FDA) labeling, Spravato is only to be distributed to certified pharmacies, healthcare providers and specialty distributors in the Risk Evaluation and Mitigation Strategy (REMS) program due to the risk of serious adverse outcomes. This requires all pharmacies to be REMS-certified and only dispense Spravato to health care settings certified in this program as well.

 

Providers are no longer permitted to use “pharmacy bill” methodology for Spravato (HCPCS code S0013 and J3490). Instead, TRICARE only allows providers to buy-and-bill for the drug when rendering care, by utilizing G2082-83 code.

 

Humana Military is actively working with the Defense Health Agency (DHA) to learn more about the details of this change, and we will continue to share information as it becomes available.  

 

Learn more about the REMS buy-and-bill application.

Autism Care Demonstration (ACD) update

February 14, 2024

Effective January 24, 2024, all Applied Behavior Analysis (ABA) outcome measures be completed no earlier than 90 days prior to their respective due date. Please be aware of all respective outcome measure due dates to prevent a delay in authorization of services. For more information, see TRICARE Operations Manual (TOM) Ch. 18, Sec. 4, Para. 8.6.4.7.

Cystic Fibrosis (CF) coverage extended under the Laboratory Developed Tests (LDT) demonstration

February 9, 2024

TRICARE recently extended coverage for preconception and prenatal Cystic Fibrosis (CF) carrier screening, as well as the follow-on prenatal CF diagnostic genetic testing, such as amniocentesis, chorionic villus sampling, or chordocentesis, when provided in accordance with the most current American College of Obstetricians and Gynecologists (ACOG) guidelines.

 

Additionally, this screening is exempt from the preauthorization requirements of this demonstration.

 

It’s important to note, that this change also updated the naming convention of these types of tests from “Non-FDA approved LDTs” to “FDA Non-Approved LDTs.”

 

For more information, please see TRICARE Operations Manual (TOM) Ch. 18, Sec. 3, Para 2.2, Change 133.

Billing update to End Stage Renal Disease (ESRD) facilities

January 26, 2024

Billing update to End Stage Renal Disease (ESRD) facilities

TRICARE no longer considers ESRD facilities (freestanding kidney dialysis centers) as Corporate Services Providers (CSP). These freestanding ESRD facilities are now recognized as authorized institutions for reimbursement and certification requirements and must meet the following criteria for reimbursement as listed in TRICARE Policy Manual Chapter 11, Section 2.10:

  • Be classified as a freestanding ESRD facility by Medicare and be Medicare-certified
  • Be a TRICARE participating provider, and
  • Agree to accept the TRICARE payment as full payment for the care, services or supplies

 

Freestanding ESRD providers that meet the above requirements will be authorized as TRICARE institutional providers. Providers who do not meet the criteria will no longer receive TRICARE reimbursement as a CSP for dates of services on or after January 12, 2023.

 

This change aligns TRICARE with Medicare for reimbursement which includes a limitation of three dialysis sessions per week unless medical justification is provided and approved. Freestanding ESRD facilities should seek reimbursement for the facility/institutional component of dialysis sessions on a UB-04 claim form.

 

See TRICARE Reimbursement Manual (TRM), Ch. 18, Sec. 1 for more information on this change and its requirements.

 

Find out more about covered dialysis services in the TPM, Ch. 7, Sec. 4.2.

 

Find out more: ESRD Prospective Payment System (PPS) consolidated billing

 

View ERSD FAQs

New Technology Add-On Payment (NTAP) update

January 26, 2024

TRICARE has established criteria for pediatric NTAPs, as well as an approval process for a new technology to be considered for a TRICARE-designated NTAP. 

 

Pediatric-Specific NTAPs 

Pediatric NTAP inpatient hospital claims may be applied when reimbursement is equal to the lesser of 100% of:

  • the average cost of the technology, or
  • 100 % of the total covered costs that exceeds the Medicare Severity-DRG payment.

Pediatric-specific NTAPs apply to hospital discharges on or after July 1, 2022.

For more information, see TRICARE Reimbursement Manual (TRM), Ch. 6, Sec. 11, Para 4.3.

 

TRICARE-Designated NTAPs

Instances of TRICARE-covered services and supplies without a Medicare-established NTAP adjustment for Diagnosis Related Groups (DRG), may require DHA to designate a TRICARE NTAP adjustment. Technology manufacturers may request to be considered for a new TRICARE-designated NTAP by submitting this application.

 

The deadline for receipt of application is July 8 of the preceding fiscal year for the TRICARE NTAP to be considered.

 

For more information, see TRM, Ch. 6, Sec. 11, Para 4.5.

Stay up to date on TRICARE Select

January 5, 2024

Did you know TRICARE beneficiaries may be enrolled in TRICARE Select?  TRICARE Select is a self-managed, Preferred Provider Organization (PPO) plan available to eligible TRICARE beneficiaries who are non-active duty, not enrolled in TRICARE Prime.

 

How it works:

  • A provider must be TRICARE-authorized (any individual, institution/organization or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE)
  • Referrals are not required for most primary and specialty appointments
  • Prior authorization may be required from Humana Military for some services

 

TRICARE Select beneficiaries do not have Primary Care Managers (PCM) and may self-refer to any TRICARE-authorized provider. However, certain services (e.g., inpatient admissions for substance abuse disorders and behavioral health, adjunctive dental care, home health services) require prior authorization from Humana Military.

 

TRICARE Select is a great choice for your patients who:

  • live in an area where they can’t use TRICARE Prime
  • have Other Health Insurance (OHI)
  • are seeing a provider who isn’t in the TRICARE network and don’t want to switch

 

Eligible beneficiaries pay an annual outpatient deductible, cost-shares (or percentage) for covered services and Group A retirees must pay enrollment fees.

 

Find out more about TRICARE Select and encourage beneficiaries to enroll today!

Reimbursement changes for Home Health Agencies (HHA)

January 5, 2024 update

The Notice of Admission (NOA) was not adopted by the Defense Health Agency (DHA) so they are no longer required.

 

TRICARE Reimbursement Manual (TRM) Ch 12, Sec 9

Home Health Agency (HHA) reimbursement FAQs

 

February 6, 2023 update

 

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

 

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.

 

June 15, 2022 update

 

Update Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).

 

March 4, 2022 update

 

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

 

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

 

Retroactive to January 1, 2021, TRICARE has implemented the following changes.

 

National Operating Standard Cost as a Share of Total Costs (NOSCASTC)

 

The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.  

 

Split percentage payments and Requests for Anticipated Payment (RAP)

 

HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.  

 

Low Utilization Payment Adjustment (LUPA)

 

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.

 

Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.

eSHARE makes monthly provider roster submissions easier

January 5, 2024

Simplify the way you update provider data! The eSHARE electronic platform saves you time and reduces email. Using the provided template, monthly roster submissions are simpler than ever.

eShare helps providers and practices:

 

  • Control how your data appears in Humana Military’s system
  • Benefit from secure, simple and fast submissions
  • Have access 24/7 access
  • Submit your update when it is convenient for you
  • Receive instant confirmation of your acceptance
  • Receive instant alerts and instructions if additional information is needed

 

Roster changes are processed in less than 30 days.

 

Contact your Humana Military TRICARE Community Liaison (TCL) to sign up and to learn more!

Automatic Blood Pressure Monitors (BPM) coverage update

December 22, 2023

TRICARE has added coverage for automatic Blood Pressure Monitors (BPM), under TRICARE’s Durable Medical Equipment (DME) policy (TRICARE Policy Manual (TPM), Chap.8, Sect. 2.1), for patients receiving covered Remote Physiologic Monitoring (RPM) services for medically necessary blood pressure monitoring.

 

Exclusions to this coverage include:

 

  • Automatic blood pressure monitors that do not meet the TRICARE Program’s definition or coverage requirements for DME
  • Automatic BPMs for patients not receiving covered RPM services for blood pressure monitoring
  • Manual blood pressure monitors

 

Reference TPM Chap. 8, Sect. 2.1 for more information about this change and RPM services.

Automatic Blood Pressure Monitors (BPM) coverage update

December 22, 2023

TRICARE has added coverage for automatic Blood Pressure Monitors (BPM), under TRICARE’s Durable Medical Equipment (DME) policy (TRICARE Policy Manual (TPM), Chap.8, Sect. 2.1), for patients receiving covered Remote Physiologic Monitoring (RPM) services for medically necessary blood pressure monitoring.

 

Exclusions to this coverage include:

 

  • Automatic blood pressure monitors that do not meet the TRICARE Program’s definition or coverage requirements for DME
  • Automatic BPMs for patients not receiving covered RPM services for blood pressure monitoring
  • Manual blood pressure monitors

 

Reference TPM Chap. 8, Sect. 2.1 for more information about this change and RPM services.

Update to ultrasound surgery coverage details

December 20, 2023

Effective December 20, 2023, unilateral thalamotomy using Magnetic Resonance Image Guided Focused Ultrasound Surgery (MRgFUS) (CPT code 0398T) may be covered for the treatment of medication refractory essential tremor when:

  • Provided with FDA-approved devices and
  • In accordance with the American Society for Stereotactic and Functional Neurosurgery coverage criteria

 

For more information, see TRICARE Policy Manual (TPM) Chap.4, Sect. 20.1, Para. 2.14. 

Referrals and authorizations are going digital!

December 18, 2023

Humana Military is preparing to move all referrals and authorizations to electronic submissions, eliminating hard copy fax receipts. Instead, you can submit multiple documents for new and existing referrals/authorizations through provider self-service. If you have not yet done so, please adjust your referral/authorization processes now to prepare for this upcoming change.

 

If you are not currently using electronic submissions, are unable to access provider self-service or have barriers when attempting to use electronic submissions for your referrals or authorizations, please fill out this survey let us know how we can help you.

 

If you need a self-service account to begin submitting online you can create one today! For those providers who are already submitting referrals and authorizations through provider self-service- thank you!

 

See referrals and authorizations or referral/authorization demonstration or FAQs.

Changes to Freestanding Ambulatory Surgery Centers (ASC) reimbursement effective Oct. 1

December 18, 2023

Effective for service dates on or after October 1, 2023, TRICARE policy requires claims for care rendered at freestanding Ambulatory Surgery Centers (ASC) to process using the Medicare ASC Payment System for reimbursement. See the TRICARE Reimbursement Manual (TRM) Ch. 9, Sec. 2 Ambulatory Surgical Center (ASC) Reimbursement for service on or after October 1, 2023, for additional details. 

 

Freestanding ASCs that specifically service pediatric populations, and do not have a Medicare participation agreement, must be accredited by the Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC) and enter into a participation agreement with TRICARE.

 

Please see the following general guidance on claims reimbursement:

  • Freestanding ASCs that do not meet all of the above Medicare eligibility requirements are no longer eligible for reimbursement for services rendered on or after October 1, 2023.
  • For freestanding ASCs that meet the Medicare eligibility requirements, Humana Military will hold claims for their services rendered on or after October 1, 2023, until further guidance is received.  
  • For services rendered before October 1, 2023, claims will be processed using the rates found on Ambulatory Surgical Center (ASC) Payment page

 

For more information about this TRICARE policy change, visit the TRM, Ch. 9, Sec. 2

 

For more information on participating with Medicare, providers should contact the Centers for Medicare & Medicaid Services (CMS)

 

Please check back regularly as this article will be updated with the latest information.

Change to accessing basic referral information

December 18, 2023

As of December 18, 2023, Humana Military is no longer able to provide basic referral status information through the call center. To obtain this information, you must log in to your provider self-service account, or call the automated and interactive self-service phone line at (800) 444-5445.

 

Any referral issues or questions not related to basic referral details will be performed via the call center as normal. Basic referral details includes details available in self-service like effective dates, number of visits, referral status, expiration dates and type of service.

 

For more information on provider self-service account registration and accessing referral details, please visit our on-demand webinar library and view the tip sheet on TRICARE referrals and prior authorizations.

Coverage update to Mobile Medical Applications (MMA)

December 1, 2023

TRICARE recently clarified coverage criteria for Mobile Medical Applications (MMA) and related sensors based on existing TRICARE policy and regulations.

 

Per TRICARE policy, there are currently no MMAs that meet TRICARE coverage criteria. Once an MMA meets all criteria, the relative paragraph will be updated in the TRICARE Policy Manual (TPM).

 

TPM Ch 1, Sec 1.2, Para. 1.1.68 states “Mobile Medical Applications (MMAs) and other digital therapeutics are excluded unless listed as covered by the TRICARE Program in TPM Ch. 8, Sec.2.1, Para. 3.12.5.”

Rare diseases and fetal surgery coverage update

October 20, 2023

On November 13, 2023, TRICARE is adding coverage of fetoscopic and other minimally invasive surgery for the treatment of a rare disease, myelomeningocele (MMC). Cost-sharing may be considered when the gestational age of the fetus is 19.0 to 25.9 weeks and MMC is present with an upper boundary located between T1 through S1 with evidence of hindbrain herniation.

 

For more information, see TRICARE Policy Manual (TPM) Ch. 1, Sec 3.1, Para 2.31 and TPM Ch. 4, Sec.18.5.

Change to cancer and children’s hospital Outpatient Prospective Payment System (OPPS) reimbursement methodology

October 19, 2023

Effective for dates of service on or after October 1, 2023, cancer and children’s hospitals TRICARE maximum allowed reimbursement methodology for outpatient claims will begin to process using the Outpatient Prospective Payment System (OPPS) (TRICARE Reimbursement Manual (TRM), Ch. 13, Sec. 1, Para. 3.4.1.1.5), and blended rates for radiology will end (TRM, Ch. 1, Sec. 24, Para. 2.9.7).

 

For more information on the OPPS billing and reimbursement policy see Ch. 13. To learn more about the hold-harmless provision, see TRM Ch. 13, Sec. 3, Para. 3.1.5.8.

 

For more information about these changes to TRICARE reimbursement methodology, visit our FAQs.

Avoid improper billing practices

September 1, 2023

Providers that make coding decisions that result in overbilling are committing fraud. Abuse can occur when a provider's billing practices, which may be direct or indirect, causes a financial loss even if there is not intent. One example of these practices that lead to overbilling is known as unbundling.

 

Unbundling occurs when multiple procedures/services are improperly billed separately, even though the group of services is covered by a single comprehensive code.  It can result in a higher reimbursement than the provider is entitled to receive.

 

Appending unwarranted modifiers to override the claims auditing software and allow additional payment for services that would normally be bundled is also considered fraudulent.

 

Unbundling fraud in the TRICARE program results in unlawful reimbursement at the taxpayer’s expense.  TRICARE providers are required to abide by all TRICARE program and Humana Military rules and guidelines for coding that are applicable when billing for services provided to beneficiaries. Manipulating CPT codes as a means of increasing reimbursement is considered improper billing practices and a misrepresentation of services billed.

 

Examples of fraud:       

  • Billing for costs of nonchargeable services, supplies or equipment disguised as covered items
  • Misrepresentations of description of services rendered

Update to Laboratory Developed Test (LDT) demonstration

August 18, 2023

The Laboratory Developed Test (LDT) demonstration has been extended through July 18, 2028, and the following LDTs have been added: 

  • Biotheranostics Breast Cancer Index
  • DermTech Pigmented Lesion Assay (PLSA)
  • FoundationOne Heme
  • MDxHealth Confirm MDx 
  • MDxHealth Select MDx

 

Cystic Fibrosis (CF) carrier screening is now covered under the TRICARE basic benefit as a preconception and prenatal carrier screening test, as well as under the LDT demonstration for the following indications:

  • confirmation of diagnosis in individuals showing clinical symptoms of CF or having a high sweat chloride level
  • identification of newborns who are affected with CF
  • identification of individuals with the p.Gly551Asp variant who will respond to treatment with ivacaftor
  • male infertility testing and treatment

 

Learn more about LDTs

 

TRICARE Manuals - Chap 18 Sect 3 (Change 125, Jul 28, 2023) (health.mil)  

Referrals and authorizations are going digital!

August 22, 2023

Humana Military is preparing to move all referrals and authorizations to electronic submissions by the end of 2023 and will no longer accept hard copy faxes. Through provider self-service, you can submit multiple documents for new and existing referrals and authorizations.  

 

If you are not currently using electronic submissions, are unable to access provider self-service or have barriers when attempting to use electronic submissions for your referrals or authorizations, please fill out this survey to let us know how we can help you.

 

If you need a self-service account to begin submitting online you can create one today! For those providers who are already submitting referrals and authorizations through provider self-service- thank you!

 

See referrals and authorizations or referral/authorization demonstration or FAQs

New basic eligibility verification policy

June 9, 2023

Effective July 24, 2023, providers will no longer be able to obtain basic eligibility details from the call center and must use either self-service or call our automated system at (800) 444-5445.

 

Basic eligibility details include benefit and coverage types, sponsor information, effective dates, copay and cost-share info, catastrophic cap, deductibles and Other Health Insurance (OHI) information can be found in self-service!

 

Any eligibility issues or questions not related to basic eligibility verification will be performed via the call center as normal.

 

For more information, check out the Provider Eligibility FAQs.

Silicon Valley Bank (SVB)/ Signature Bank closures

March 17, 2023

The Federal Deposit Insurance Corporation (FDIC) announced that it has assumed control of Silicon Valley Bank (3/10/23) and Signature Bank (3/12/23) to meet the needs of its depositors and ensure there are no risks to the account holders. As such, the FDIC has established bridge banks and moved all deposits to these respective banks to ensure access by the account owners with little interruption of services. This process should be seamless to the account holders; more information is available on the FDIC website.


Earlier this week, claims payments were suspended for providers with these banking arrangements until the initial assessment of this issue was compete. The assessment is now complete and at this point, we do not see an inherent issue with provider payments based on the information available from the FDIC. As such, payments currently held will be released and issued in the normal time frames.


If providers wish to change their current payment arrangements to a different bank or select paper checks, they can visit the WPS/Change Healthcare portal for Electronic Funds Transfer (EFT)/ Electronic Remittance Advice (ERA) or learn more by viewing these FAQs on how to change a healthcare payer’s enrollment services.


We apologize for any inconvenience this may cause, but we wanted to ensure receipt of payments in a secure manner for the services provided. Please reach out to your local TRICARE Community Liaison (TCL) should you need further assistance.

Access to Spravato®

March 16, 2023

The nasal spray, Spravato® (esketamine), is covered when deemed medically necessary to treat beneficiaries with treatment-resistant depression and other US Food and Drug Administration (FDA)-approved indications, which are available in the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program. This benefit is covered under the medical benefit, not pharmacy, and prior authorization is required.

While Walgreens is not a network provider at this time, prescriptions for Spravato (esketamine) can be filled through Walgreens Specialty Pharmacy.

Reimbursement changes for Home Health Agencies (HHA)

February 6, 2023 update

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.
 

TRICARE Reimbursement Manual (TRM) Ch 12, Sec 9

Home Health Agency (HHA) reimbursement FAQs
 

June 15, 2022
 

Update Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).


March 4, 2022 - Update
 

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

Retroactive to January 1, 2021, TRICARE has implemented the following changes.


National Operating Standard Cost as a Share of Total Costs (NOSCASTC)
 

The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.


Split percentage payments and Requests for Anticipated Payment (RAP)
 

HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.


Low Utilization Payment Adjustment (LUPA)
 

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.

Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.

Update to TRICARE's Childbirth and Breastfeeding Support Demonstration (CBSD)

August 24, 2023

TRICARE’s Childbirth and Breastfeeding Support Demonstration allows Certified Labor Doulas (CLD), lactation consultants or lactation counselors to provide care to eligible beneficiaries.

 

Effective July 25, the following telemedicine services for the CBSD are no longer included:

  • Audio-only breastfeeding counseling
  • Antepartum and postpartum care visits

 

Please note: All childbirth support services provided by a Certified Labor Doula (CLD) must be in-person.

 

As a reminder, providers must use a two-way visual component to provide breastfeeding support services via telemedicine.

 

To verify you are able to continue to provide these services, please review Telemedicine for providers.

 

For more information on the CBSD, visit TRICARE Operations Manual and CBSD provider resources.

Get the latest on the COVID-19 Public Health Emergency ending

May 16, 2023

The COVID-19 Public Health Emergency (PHE) expired on May 11, 2023 along with TRICARE’s temporary coverage and payment for certain services. As a result, key impacts due to the expiration of the PHE include (but are not limited to):

Relaxation of state professional licensing requirements

The temporary relaxation of state professional licensing requirements has expired.

 

TRICARE coverage of acute care facilities and temporary expansion of hospital sites, including Medicare’s Hospitals Without Walls (HWW) initiative

Coverage of temporary hospitals, freestanding Ambulatory Surgical Centers (ASC), and other entities enrolled with Medicare as hospitals expires upon the expiration of Medicare’s HWW initiative.

Claims for dates of services through the PHE expiration date will continue to process under the temporary classification.

Organizations previously considered a TRICARE-authorized, freestanding ASC may return to that classification, provided all federal and state licensure/certification requirements are current.

If your organization wishes to participate in TRICARE as a hospital and has been certified as such by Centers for Medicare & Medicaid Services (CMS) or The Joint Commission (TJC), please visit HumanaMilitary.com/certify to submit a hospital application.

 

Certain Critical Access Hospital (CAH) participation requirements

The requirements that CAHs provide 24-hour emergency care services and no more than 25 beds for acute, hospital-level inpatient care, or swing beds for Skilled Nursing Facility-Level care, and maintain a length-of-stay of no more than 96 hours, determined annually, expire.

You can visit TRICARE Coverage and Payment for Certain Services in Response to the Coronavirus Disease 2019 (COVID-19) Pandemic for complete details on each amendment to TRICARE policy.

 

Skilled Nursing Facilities (SNF) three-day prior hospital stay requirement waiver

The waiver for a qualifying hospital stay of three consecutive days or more, not including hospital discharge day, prior to SNF admission, expired on April 10, 2023 with the President’s termination of the national emergency.

You can visit Temporary Reimbursement Changes In Response To The Coronavirus Disease 2019 (COVID-19) Pandemic for complete details.

Increase to number of milk bags covered every 30 days

May 10, 2023

Starting on May 3, 2023, TRICARE now allows a refill of 100 breast milk supply bags every 30 days following a birth event. This is an increase from 90 bags.

 

Learn more

Clarification on Partial Hospitalization Programs (PHP) claims and codes

June 21, 2023

When billing Partial Hospitalization Program (PHP) services, revenue codes 0913 or 0912 should be filed with the correct Healthcare Common Procedure Coding System (HCPC) code to allow the system to calculate the appropriate allowed amounts to ensure proper payment.

 

Note: Revenue codes must be billed separately for each date of service.

 

Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) claims are to be submitted per policy as listed below:

 

Non-Outpatient Prospective Payment System (OPPS) payable providers

  • Revenue code 0912 can be billed with HCPCS H0035 or by itself for half-day service
  • Revenue code 0913 can be billed with HCPCS H0037 or by itself for full-day service
  • Revenue code 0905 or 0906 can be billed with H0015 or S9480

 

OPPS payable providers

  • Revenue codes 0914 and 0915 are payable only to OPPS providers. Please reference figure 13.2.1 for the listing of OPPS payable HCPCS codes referenced in the TRICARE Reimbursement Manual provided below
  • Revenue code 0905 or 0906 can be billed with H0015 or S9480
  • All claims must be billed with condition code 41 on CMS 1450 UB-04 Claim Form

 

For guidance, please see TRICARE Reimbursement Manual, Chapter 13, Section 2.

 

A note on claims corrections

Claims corrections will occur on all PHP and IOP providers whose claims were incorrectly paid due to this issue. Providers will receive a details spreadsheet listing all claims that have been incorrectly billed.

 

Providers will have the option to correct either the HCPCS code or revenue code. To correct the spreadsheet, add the correct code to the column which best represents the service provided. After reviewing all claims on the spreadsheet and updating the column appropriately. This will serve as documentation to make corrections to the claims. Send the file to the email or mailing address below.

 

Recoupment action will be initiated 60 days after the date of this notice for all claims that were overpaid if no action is received from the provider. The provider can submit a corrected claim.

 

Email

TRICAREEastProviderInquiry@humana.com

 

Mail

TRICARE East Region claims

Attn: Corrected claims

PO Box 8904

Madison, WI 53708-8904

 

Fax

(608) 327-8523

Submit your certification applications digitally

September 1, 2023

*Humana Military has moved all certification applications to a digital format, and starting October 1, 2023, will no longer accept paper or PDF applications. Providers who submit paper versions on or after October 1 will receive a letter back that they need to complete their application electronically, potentially delaying the certification process.

 

Please dispose of any paper applications or PDFs you have on hand, and instead access our most current, digital versions at HumanaMilitary.com/certify.

 

What are the benefits of digital certification applications?

  • Faster processing time
  • Instant electronic confirmation of receipt
  • Check applicaiton status online
  • Improved submission accuracy
  • Real-time feedback
  • Captures all necessary attachments
  • Prevents submission of incomplete applications
  • Less touchpoints—no need to call or email to confirm receipt or follow-up

 

Thank you for your cooperation as continue to work to enhance the certification application process.

 

*After October 1, the only remaining print certification applications will be Telehealth Only applications.  

Abortion billing tips

November 30, 2022

To receive correct reimbursement, please ensure all required information is included, per TRICARE Policy Manual (TPM) Chapter 4 Section 18.3.


Claims must be submitted with the following:
 

G7 modifier, which is defined as the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening

One of the condition codes listed below: 

AA - Abortion performed due to rape;

AB - Abortion performed due to incest;

AD - Abortion performed due to life endangering physical condition

For more information, visit TRICARE.mil.

Provider 2020 - 2021 Archival Articles

Archive 2020 - 2021

Updated Autism Care Demonstration (ACD) concurrent billing information

December 13, 2021

Per TRICARE policy, concurrent billing is not permitted. Only one code should be billed when concurrent care services are performed. If both are billed concurrently TRICARE will pay the higher charge and deny the lesser. If the lesser charge is received first, TRICARE will pro-rate the higher charge.

Note: When billing any session, please remember to enter the appropriate units rendered for the applicable procedure code.

For additional guidance see the TRICARE Operations Manual, Chapter 18, section 3, 8.11.7.3.8

Concurrent billing is excluded for all ACD Category I CPT codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. Documentation must indicate two separate rendering providers and locations for the services.

·  The contractor shall pay the higher rate and deny the other if CPT codes 97153 and 97155 are billed concurrently.

 

 

CPT CODES

 

 

 

 

97151

 

 

 

 

97153

 

 

 

 

97155

 

 

 

 

97156

 

 

 

 

97157

 

 

 

 

97158

 

 

 

 

97151

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97153

 

 

 

 

Y

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97155

 

 

 

 

N

 

 

 

 

N

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97156

 

 

 

 

Y

 

 

 

 

Y

 

 

 

 

Y

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97157

 

 

 

 

Y

 

 

 

 

Y

 

 

 

 

Y

 

 

 

 

N

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

97158

 

 

 

 

Y

 

 

 

 

N

 

 

 

 

N

 

 

 

 

Y

 

 

 

 

Y

 

 

 

 

N/A

 

 

 

Basic claim status inquiries

December 8, 2021

Providers performing basic claim status inquiries must now use provider self-service or the automated claim status function by calling (800) 444-5445. Basic status inquiries sent via secure message or chat will also be directed back to self-service.

Basic claim status inquiries include details available in self-service like claim status, processed and paid date, billed and allowed amounts, amount paid and more.

Any claims issues or questions not related to basic claim status will be performed via the call center as normal.

For more information, check out our Provider Resources FAQ

 

Cologuard™ referral is no longer required for TRICARE Prime beneficiaries, effective 6/1/22

UPDATE: May 5, 2022

Exact Science has now joined the network and referrals are no longer required for dates of service on or after 6/1/22.

Find out more about colorectal cancer screenings and other covered clinical preventive services

November 10, 2021

TRICARE will cover stool DNA testing (e.g. Cologuard™) once every one to three years starting at age 45 for those who have an average risk of colon cancer. Exact Science, (the only laboratory provider that offers Cologuard), is considered non-network for TRICARE Prime. Therefore, an approved referral is required for Prime beneficiaries prior to testing or Point of Service (POS) will apply.

 

Clinical preventive services policy update

October 20, 2021

Effective May 18, 2021, TRICARE revised the clinical preventive services policy.

The following sections of the TRICARE policy manual were revised for clinical preventive services:

Colorectal cancer screening

  • Revised coverage frequency and age limit for individuals at average risk from age 50 to age 45

  • Fecal Immunochemical Testing (FIT) of one stool sample once every 12 months beginning at age 45

  • Food and Drug Administration (FDA) approved Fecal Immunochemical Testing (FIT-DNA) stool tests (e.g. Cologuard™) once every one to three years beginning at age 45

  • Flexible sigmoidoscopy covered once every five years beginning at age 45

  • Computed Tomographic Colonography (CTC) covered once every five years beginning at age 45

  • Optical (conventional) colonoscopy covered once every 10 years beginning at age 45

  • Noted that screening guidelines are no longer specific to those with an increased risk

  • Incorporated the American Cancer Society definition of average risk

  • Removed the definition of increased risk

Lung cancer screening

  • Revised the frequency and age interval for lung cancer screening from 55 to 50 years of age

  • Pack per year history is additionally reduced from 30 to 20 packs per year

Vision screening and services

  • Revised routine eye exam language for retirees and their family members

  • Routine eye exams are not a covered benefit for retirees and eligible family members who are enrolled in TRICARE Select. Active Duty Family Members (ADFM) who are enrolled in TRICARE Select may receive a routine eye examine annually

  • Removed CPT codes 99172 - ocular function screen and 99173 - visual acuity screen from the manual

For more information, including the full definition of average risk, view TPM Chapter 7 Section 2.1

 

Updates to telemedicine Place of Service (POS) and modifier

June 24, 2022

TRICARE updated its telemedicine Place of Service (POS) codes for dates of service on or after Jan 1, 2022, and included adding POS 10 to the telehealth codes.

  • POS telehealth codes

  • POS 02 – Telehealth provided other than in patient’s home: Healthcare services delivered through video conferencing technology in a setting outside of the beneficiary’s home

  • POS 10 – Telehealth provided in patient’s home: Healthcare services delivered through videoconferencing technology in the beneficiary’s home

  • Telehealth and TRICARE

  • The use of secure video conferencing to deliver medically and psychologically necessary services to beneficiaries is covered by TRICARE. Providers should use one of the appropriate telehealth modifiers (95, GT or GQ) when billing POS 02 or POS 10. For more information on coverage and requirements, refer to TRICARE Policy Manual, Chapter 7, Section 22.1.

For more information on CMS POS codes, visit CMS.gov

October 18, 2021

When billing for synchronous telemedicine/telehealth services, providers will use CPT or Healthcare Common Procedure Coding System (HCPCS) codes with a GT or 95 modifier for distant site and Q3014 for originating site to distinguish telemedicine/telehealth services. In addition, POS 02 code may be reported in conjunction with GT or 95 modifier. However, POS 02 is not required to be reported through the end of the COVID-19 pandemic if a more appropriate code is necessary for correct billing, include POS code equal to what it would have been had the service been furnished in person. By coding and billing the GT or 95 modifier with a covered telehealth procedure code, the distant site provider certifies that the beneficiary was present at an eligible originating site when the telehealth service was furnished.

For billing asynchronous telemedicine/telehealth services, providers will use CPT or HCPCS codes with a GQ modifier. In addition, POS 02 may be reported in conjunction with the GQ modifier. However, POS 02 is not required to be reported through the end of the COVID-19 pandemic for telehealth claims if a more appropriate POS code is necessary for correct billing, include POS code equal to what it would have been had the service been furnished in person.

See TRICARE Policy Manual, Chapter 7, Section 22.1, 2.3.2 for more information.

 

Yearly provider claims update

September 24, 2021

As a reminder, TRICARE will be updating the annual Fiscal Year (FY) transactions necessary for FY 2022 from September 28 to October 1, 2021. During this time, claims will not be finalized for payment. We apologize for any inconvenience you may experience during this update.

Please see the below anticipated timeline for awareness and for the normal return to payment processing due to the transition:

  • September 28-October 1: No processing for payments

  • October 1: Payment processing will slowly resume

  • October 6: Expectation to full, normal processing times

*Please note: During this time, provider self-service may indicate a claim has been paid, but it may not have been processed.

 

Freestanding ER claims verification

September 13, 2021

Humana Military is working diligently with the Defense Health Agency (DHA) to resolve the matter of the recoupments from freestanding Emergency Room (ER) claims that are currently on hold. We are moving forward to find a solution pending DHA's decision from its "emergency services rendered by non-authorized providers" policy.

See Freestanding ER FAQ's for more information.

 

Durable Equipment (DE) and Durable Medical Equipment (DME), Prosthetics, Orthotics, And Supplies (DMEPOS)

September 3, 2021

Reimbursement for Durable Equipment (DE) and Durable Medical Equipment (DME), Prosthetics, Orthotics and Supplies (DMEPOS) is established by an all-inclusive DMEPOS fee schedule. Currently, the reimbursement rates are based on Medicare’s DMEPOS and Parenteral and Enteral Nutrition (PEN) fee schedule amount. If there is no Medicare rate, the DE or DMEPOS item or service will be reimbursed using state prevailing rates.

Starting November 11, 2021, reimbursement rates will use the following methodology:

  • The reimbursement rate is based on Medicare’s DMEPOS and PEN fee schedule amount. The pricing files are available on the CMS website

  • If there is no Medicare rate, the DE or DMEPOS item or service will be reimbursed using TRICARE’s DMEPOS fee schedule rates.

  • If there is no Medicare or TRICARE DMEPOS fee schedule rate, the DE or DMEPOS item or service will be reimbursed using state prevailing rates.

When billing DE, DMEPOS, or PEN items, the provider must:

  • report the number of units based on the description of the Health Common Procedure Coding System (HCPCS) code and

  • always include the modifier code RR on rental items and modifier code UE on used items. Any HCPCS codes billed with the UE modifier will result in a 25% reduction in the purchase rate listed in the TRICARE DMEPOS fee schedule.

The fee schedule and periodic adjustments will be posted on the DHA website

See the TRICARE Reimbursement Manual (TRM) Chapter 1, Section 11 for more information.

Wigs and hairpieces

TRICARE covers one wig (also known as cranial prosthesis) or hairpiece per beneficiary (lifetime maximum) when the attending physician certifies that alopecia has resulted from the treatment of a malignant disease and the beneficiary certifies that a wig or hairpiece has not been obtained previously through the U.S. Government. This includes the Department of Veterans Affairs/Veterans Health Administration (DVA/ VHA). For more information on this benefit, refer to TRICARE Policy Manual (TPM) Chapter 8, Section 12.1

For Calendar Year (CY) 2021, the allowable charge per wig or hairpiece cannot exceed the published CY rate of $2,388. If the wig or hairpiece exceeds this maximum amount, the reimbursement will be up to the allowable amount. The government will update this amount annually, using the Consumer Price Index-Urban (CPI-U), and publish them online

08/31/2021

DHA extends deadline to submit new participation agreement

Due to a low response from Autism Corporate Service Providers (ACSP) in submitting a new participation agreement to remain TRICARE-authorized, the Defense Health Agency (DHA) has issued an extension through September 15, 2021.

Per TRICARE Operations Manual (TOM), ACSPs (including sole providers) must enter into a participation agreement. These providers practicing prior to July 1, 2021, must re-sign all of their participation agreements no later than September 15, 2021 or risk terminating their TRICARE- authorized status.

To fulfill the new policy requirement, ACSPs should submit a new certification before September 15, 2021. See TOM, Chapter 18, Section 4, paragraph 8.3 for more information on this requirement.

NOTE: Individual Behavior Analysts, Assistant Behavior Analysts, and Behavior Technicians working under tiered delivery models do not need to complete the ACSP application.

Submit new certification now

Additional DHA-requested changes include:

Per TOM Chapter 18, Section 4, paragraph 8.2.1, all ABA practitioners must obtain a National Provider Identifier (NPI) number (all claims must have the rendering provider’s name and NPI for processing). Claims will deny for any ABA providers (including Assistant Behavior Analysts and Behavior Technicians) who did not possess an NPI prior to August 1, 2021. Visit self-service to add or update an NPI.

Add or update NPI

DHA also requires all ABA providers to submit claims and receive payments electronically (location-specific) through Electronic Media Claims (EMC) and Electronic Fund Transfers (EFT).

Learn more about EMC and EFT

 
 

 

Ablative Fractional Laser (AFL) treatment for burns and scars

August 30, 2021

Ablative Fractional Laser (AFL) treatment is approved under provisional coverage for emerging services and supplies. It includes Carbon Dioxide (CO2), Erbium, and Yttrium aluminum garnet laser treatments for symptomatic scars resulting from burns or other trauma.

AFL is covered for the treatment of symptomatic burns and scars with one or more of the following symptoms: itch, burn, pain, tightness, ulcerations or physical functional impairment.

Examples of physical functional impairment include, but are not limited to:

  • decreased range of motion with use of associated body part

  • problems with communication, respiration, eating, swallowing

  • visual impairments

  • skin integrity

  • distortion of nearby body parts

  • obstruction of an orifice

Preauthorization is NOT required.

AFL treatments are excluded for the following reasons:

  • social, emotional and psychological impairment or potential impairments

  • solely for cosmetic purpose (unless otherwise covered under Chapter 4, Section 2.1)

Procedure codes: 0479T OR 0480T

Reimbursement: Reimbursed as professional service, at rates equivalent to CPT codes 17280/17286 Note: Rates will be updated each time TRICARE updates the CHAMPUS Maximum Allowable Charge (CMAC) rates for CPT codes 17280/17286.

TED Special Processing Code: AT (Must be used since the codes are on the Government No Pay List – DHA is allowing us to bypass)

Effective dates are February 24, 2021 through February 23, 2026 (five years), with the implantation date of September 27, 2021.

See: TRICARE Policy Manual Chapter 13, Section 1.1

 
 

 

Remote Physiologic Monitoring (RPM)

August 9, 2021

Medically necessary RPM services of physiologic parameter(s) including, but not limited to, weight, blood pressure, pulse oximetry and respiratory flow rate are covered when:

  • The beneficiary requires RPM services of at least 20 minutes of clinical staff time directed by a TRICARE-authorized provider, per 30-day period; and

  • The beneficiary has a comprehensive care plan established, implemented, revised or monitored; and one of the following criteria are met:

  • The beneficiary has a chronic condition(s) that is expected to last at least 12 months, or until death of the beneficiary; or

  • The beneficiary has an acute condition(s) that place the beneficiary at significant risk of death, acute exacerbation/decompensation, or functional decline.

Monitoring devices and equipment must be US Food and Drug Administration (FDA) approved and meet the definition of Durable Equipment (DE) and/or Durable Medical Equipment (DME). Examples of devices and equipment that do not meet TRICARE’s definition of DE/DME include personal computers, smartphones, tablets, smart watches, non-medical trackers and weight scales.

Covered services include:

  • Set-up and patient/caregiver education on use of equipment (Current Procedural Terminology (CPT) code 99453);

  • Device supplies with daily recordings/alert transmission, each 30 days (CPT code 99454);

  • RPM treatment management services, TRICARE-authorized provider time per calendar month requiring interactive communication with the patient/caregiver for the first 20 minutes (CPT code 99457); and

  • The collection and interpretation of physiologic data digitally stored and/or transmitted by the patient/caregiver to the TRICARE- authorized provider with a minimum of 30 minutes of collection and interpretation time each 30 days (CPT code 99091).

  • Remote assessment of recorded video and/or images submitted (e.g., store and forward), including interpretation and follow-up with the beneficiary within 24 hours (HCPCS G2250).

CPT procedure codes 99091, 99453, 99454, 99457, 99458 / HCPCS code G2250

RPM is considered an ancillary service as defined in TRICARE Reimbursement Manual (TRM), Chapter 2, Section 2, paragraph 2.7.4. Ancillary service cost-shares and copayments will apply.

 
 

 

A temporary work-around has been established to begin processing 2021 NO-PAY RAP claims

08/06/2021

WPS will begin processing HHA Request for Anticipated Payment (RAP) claims, bill type 322, with a work-around for the 2021 RAP NO-PAY processing guidelines.

The RAP claims will be processed with a temporary Denial Reason Code of 020. This charge is considered included in A Paid Service, until the final system update is completed and the actual DRC is moved into production along with the 2021 HHA pricer release.

When the Explanation of Benefit (EOB) is received with the 020 DRC, please disregard the statement that indicates to follow the steps to submit an allowable charge review for the RAP claim denial.

If there are any questions, please reach out to your local TRICARE Community Liaison (TCL) or a customer service representative for additional assistance.

 
 

 

COVID ABA telemedicine expiration

August 5, 2021

Beneficiaries with current authorizations for CPT code 97156 (Patient/Caregiver Guidance) can no longer receive unlimited telemedicine visits. Additional telemedicine visits for parent training will require prior approval.

Beneficiaries who enter the Autism Care Demonstration (ACD) after August 1, 2021 cannot be administered care via telemedicine for CPT code 97156 (Patient/Caregiver Guidance) until after the first six months of the authorization period.

Providers should be aware that the TRICARE Operations Manual (TOM) Chapter 18 Section 4 for ACD claims reimbursement will be followed.

For more information on autism and the most recent updates on changes to the ACD, visit Comprehensive Changes to the Autism Care Demonstration

 
 

 

ACSP must submit new certification request between July 1 and August 1

June 15, 2021

Due to the recent Autism Care Demonstration (ACD) changes in TRICARE ABA policy, all Autism Corporate Service Providers (ACSP) must submit a new participation agreement between July 1 and August 1, 2021 or risk terminating their TRICARE authorized status. ACSPs include autism centers, autism clinics, and sole providers (regardless of setting of rendered ABA services, i.e., home or clinic).

To fulfill the new policy requirement, ACSPs should visit this link: 
Submit this new certification before August 1

See TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.3 for more information on this requirement.

Note: Individual Behavior Analysts, Assistant Behavior Analysts, and Behavior Technicians working under tiered delivery models do not need to complete the ACSP application.

 
 

 

Autism Care Demonstration (ACD) balance billing limitation for non-participating providers

June 2, 2021

The balance billing provisions for non-participating providers as outlined in the TRM, Chapter 3, Section 1 paragraph 4.0, do not apply.

ABA providers may not bill a beneficiary more than 100% of the rates posted at Health.mil/rates

 
 

 

Reimbursement changes for Home Health Agencies (HHA)

February 6, 2023 - Update

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.

TRICARE Reimbursement Manual Chapter 12, Section 9

Home Health Agency (HHA) reimbursement FAQs 

 
 

June 15, 2022 - Update

Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).

 
 

March 4, 2022 - Update

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

 
 

May 26, 2021

Retroactive to January 1, 2021, TRICARE has implemented the following changes.
 

National Operating Standard Cost as a Share of Total Costs (NOSCASTC)

The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.
 

Split percentage payments and Requests for Anticipated Payment (RAP)

HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.
 

Low Utilization Payment Adjustment (LUPA)

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.

Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.

 

See the TRICARE Reimbursement Manual, Chapter 12, Section 9 for more information.

 
 

 

Policy clarification for acute rehabilitation facilities

May 10, 2021

As a reminder, there is no limit to the number of days for TRICARE admissions to acute rehabilitation facilities. Admissions and continued lengths of stay are based on medical necessity. Recent changes to TRICARE reimbursement methodology for acute rehabilitation facilities does not impact the length of stay for rehabilitation admissions. Discharges or transitions to other levels of care should be based upon medical necessity and the beneficiary’s overall treatment plan.

See the TRICARE Policy Manual, Chapter 7, Section 18.2, Paragraph 3.1

 
 

 

Assistant Behavior Analysts and Behavior Technicians required to submit NPI by August 1, 2021

May 5, 2021

Due to a change in TRICARE ABA policy, all previously certified Assistant Behavior Analysts and Behavior Technicians must submit their National Provider Identifier (NPI) before August 1. This update must be made through provider self-service and not by phone.

This change has been put in place to reduce errors related to provider rates and ensure providers receive correct reimbursement. View guidance on how to make a change request.

See TRICARE Operations Manual, paragraph 8.2.1 for more information on this requirement.

 
 

 

Organ acquisition services

May 12, 2022

Effective Oct. 28, 2019, TRICARE offers reimbursement for reasonable and necessary organ acquisition services and costs in support of quality organ transplant programs. Under Medicare, Certified Transplant Centers (CTC) and Organ Procurement Organizations (OPO) report these costs using the Centers for Medicare and Medicaid Services (CMS) Forms 2552 and 216. TRICARE will use the Medicare Standard Acquisition Charges (SAC) to determine reimbursement amounts.

The CTC must develop two SACs based on reasonable and necessary organ acquisition costs:

  1. A SAC for acquiring a living donor organ (estimated average charge for services provided to living donors and recipients of living donor organs)

  1. A SAC for acquiring a cadaveric donor organ (estimated average charge for procuring cadaveric organs combined with expected costs of acquiring cadaveric organs from other sources)

The SAC covers total costs for getting either live or cadaver organs. Solid organ procurement costs must be billed separately from inpatient claim with revenue codes 0811 or 0812 to be eligible for reimbursement.

TRICARE reimburses CTCs for organ acquisition one of two ways:

  1. Annually, providers should report SACs to Humana Military for organ acquisition costs for the fiscal year due July 31, 2022 by sending their information to HMHSPricingMailbox@humana.com

  1. If, for some reason, the provider is unable to report SAC by the deadline, TRICARE will use the hospital’s overall operation cost-to-charge ratio to reduce charges.

Use this SAC form to gather your information to submit to us.

For more information, see the Organ Acquisition Costs section of the TRICARE Reimbursement Manual, Chapter 1, Section 40

NOTE: If your point-of-contact information has changed, please send those updates to HMHSPricingMailbox@humana.com
 

Hospital Value-Based Purchasing Program (HVBP)

March 31, 2021

TRICARE is adopting the Centers for Medicare and Medicaid Services (CMS) HVBP for hospitals, skilled nursing facilities and other institutional providers under the Inpatient Prospective Payment System (IPPS). This program will apply a claim-by-claim adjustment factor to the base Diagnosis Related Group (DRG) payment for claims in the fiscal year associated with the acute care hospital's performance period. The adjustment factor can be found in the CMS IPPS Final Rule Table

Exclusions include those facilities not included in the IPPS:

  • Psychiatric hospitals

  • Rehabilitation hospitals

  • Long-term care hospitals

  • Children’s hospitals

  • Critical Access Hospitals (CAH)

  • Prospective Payment System-exempt TRICARE cancer hospitals

  • Hospitals in the state of Maryland

  • Hospitals located in Puerto Rico and other United States territories do not participate in HVBP. (If CMS decides at a later date to include these hospitals, TRICARE will also include them in HVBP)

See the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 41 for more information.

 
 

 

TRICARE adopts New Technology Add-On Payments (NTAP)

February 11, 2021

Effective January 1, 2020, TRICARE adopted the Centers for Medicare and Medicaid Services (CMS) New Technology Add-On Payments (NTAP) under the Medicare Inpatient Prospective Payment System (IPPS). NTAPs are special payments that are offered because new medical services and technologies are not yet included in the calculation of standardized Diagnosis Related Group (DRG) rates. A DRG is a patient classification system that standardizes prospective payment to hospitals and encourages cost-containment initiatives. By law, Medicare has established this reimbursement methodology to more appropriately pay for the costs of new medical services and technologies under the hospital IPPS.

CMS uses criteria set forth in regulation regarding the newness, clinical benefit and cost of a new technology to determine which treatments will receive an NTAP. To qualify as a NTAP, a specific technology will be “new” according to CMS regulations, specifically §412.87(b)(2). The statutory provision allows for special payment treatment for new technologies until they are incorporated into the DRG, which takes between two and three years. Once they are incorporated into the DRG, they are no longer considered NTAPs. For a complete list of NTAPs and reimbursement rules, visit the CMS website. The reimbursement amounts in the IPPS final rule represent the maximum add-on payment for each NTAP.

See the TRICARE Reimbursement Manual (TRM), Chapter 6, Section 11 for more information.

 
 

 

Known performance issues with eligibility checks

February 9, 2021

We are aware that some users may experience performance issues with eligibility checks (270/271). We are currently reviewing our real time process to address performance barriers.

270: Requests eligibility and benefit information from the patient’s insurance company.

271: Returns eligibility and benefit information of the patient. It is set to receive care from the insurance company to the provider of service.

Steps taken to date include:

  • Established a problem record to track all changes and results.

  • Adjusted memory allocation to constrained resources.

  • Reviewed anti-virus and other scanning tools for any links between scans and performance degradation.

  • Full engagement of vendor and enterprise resources on application configuration tuning to return performance to a reliable state.

The Electronic Data Interchange (EDI) team continues to push out proactive notifications to our trading partners and clearinghouses as we work through this issue.

 
 

 

Home Health Value-Based Purchasing (HHVBP) demonstration

January 14, 2021

Effective for dates of service, retroactive to January 1, 2020, Home Health Agencies (HHA) will be required to adopt the Medicare HHVBP model in TRICARE’s HHA Prospective Payment System (PPS) using the report published on the Centers for Medicare and Medicaid Services (CMS) website

The following states will be impacted by this demonstration: Florida, Maryland, Massachusetts, North Carolina and Tennessee (East Region) and Arizona, Iowa, Nebraska and Washington (West Region).

If you are a HHA impacted by this change, and have any questions about this demonstration, please contact us at HMHSPricingMailbox@humana.com

 
 

 

TRICARE Low Back Pain (LBP) and Physical Therapy (PT) demonstration

January 11, 2021

Beginning January 1, 2021, the Defense Health Agency (DHA) has approved a demonstration to waive the cost-share for up to three PT sessions for beneficiaries with LBP. The purpose of the demonstration is to evaluate if waiving cost-shares for up to three PT sessions will increase beneficiary PT participation, decrease low-value care and/or decrease the overall cost of care for treating beneficiaries with LBP.

This demonstration will run from January 1, 2021 through December 31, 2023 and will operate in the following states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee and Virginia.

See the TRICARE Operations Manual, Chapter 18, Section 9 for more information.

 
 

 

TRICARE covers certain COVID clinical trials

December 11, 2020

Effective October 30, 2020, clinical trials sponsored by or in collaboration with the National Institute of Allergy and Infectious Disease (NIAID) will be covered for the treatment and prevention of COVID-19. This change is effective for the duration of the president’s national emergency regarding COVID-19; however, if a beneficiary has been enrolled in a NIAID-sponsored trial during the national emergency, they will continue to have their cost shared for the duration of the trial, even if the public health emergency has ended.

Please use Special Processing Code (SPC) “CO – NIAID COVID-19 Clinical Trials” to identify these TRICARE Encounter Data (TED) records. This new code should be used in conjunction with “CC” whenever COVID-19 testing is included as part of a NIAID clinical trial. SPC “CO” should not be coded on the TED records with SPC “CV.”

 
 

 

TRICARE expands coverage of investigational drugs

December 11, 2020

Effective September 30, 2020, TRICARE has expanded coverage for the use of investigational drugs to treat serious or life-threatening cases of COVID-19 infection or its associated sequelae. The drugs must be approved by the US Food and Drug Administration (FDA) and administered in an FDA-approved setting.

 
 

 

New treatment approved for Obstructive Sleep Apnea (OSA)

December 11, 2020

Effective August 15, 2019, implantable Hypoglossal Nerve Stimulation (HGNS) under Common Procedure Terminology (CPT) codes 64568 and 0466T is a covered benefit for the treatment of moderate-to-severe Obstructive Sleep Apnea (OSA).

See the TRICARE Policy Manual (TPM), Chapter 4, Section 8.1 for more information.

 
 

 

Diagnostic imaging for acute Low Back Pain (LBP)

December 11, 2020

Effective October 30, 2020, TRICARE no longer provides diagnostic imaging coverage for beneficiaries with acute Low Back Pain (LBP) within six weeks of symptom onset if there were no warning signs.

If there are clinical warning signs to justify imaging within six weeks of acute low back pain onset, providers should bill with the appropriate secondary diagnosis code.

See the TRICARE Policy Manual (TPM) Chapter 5, Section 1.1 for more information.

 
 

 

New claims modifiers for breast pump supplies

Update: December 10, 2020

The new policy allows only the breast pump and the following replacement parts without an additional prescription:

  • Two bottles and caps or locking rings once a year after a birth event

  • One replacement power adapter per birth event and none within the first 12 months (Please use HCPCS code A4282 only for breast pump power adapters)

  • 12 valves or membranes once a year

  • One set of flanges per birth event

  • One set of tubing

  • 90 breast milk bags every 30 days after the birth

 

Update: October 7, 2019

Following a birth event, TRICARE allows 90 breast milk bags, every 30 days. In order to get paid correctly, providers must bill for the actual number of milk bags supplied (90), and not for a single (one) box of breast milk bags.

 

June 26, 2019

TRICARE recently revised the breast pump/breast pump supply benefit to include limits on what is covered. The changes affirm coverage of breast pumps for new mothers and adoptive mothers and allow expecting moms to access the benefit starting at the 27th week of pregnancy, or when the baby is born, if premature.

In order to correctly reimburse for breast pump supplies using unlisted Healthcare Common Procedure Coding System (HCPCS) codes A9900 or A9999, providers need to use the following modifiers:

  • Supply - Modifier

  • Replacement valves/membranes - XG

  • Replacement breast milk storage bags - XH

  • Replacement nipple shields - XD

  • Supplemental nursing system - XN

  • Breast pump kit - XR

Both the TRICARE East and TRICARE West regions are implementing these guidelines.

A supplemental nursing system, two sets of flanges and replacement supplies in addition to the above limits may be covered with a prescription that is specific to the supplies that are needed.

Additionally, TRICARE added a payment cap for manual and standard electric breast pumps. All related supplies needed for the operation of the breast pump are included in the cap amount. As of March 2019, TRICARE pays $312.84 for stateside and $500.55 for overseas. For more about these rates, visit health.mil

 
 

 

Delays in Primary Care Manager (PCM) assignment times

October 22, 2020

Please note: Due to a programming issue, we are experiencing delays in Primary Care Manager (PCM) assignment times for TRICARE Prime beneficiaries. We are working diligently to correct this issue and all PCM records should be updated by late December.

There is no need to postpone care for these beneficiaries and your claims payment should not be affected. There is no action required from you at this time.

 

COVID-19 serology testing

October 6, 2020

COVID-19 serology/antibody testing is covered by TRICARE only when medically necessary and when the results of the test will impact the clinical management of the beneficiary. For example, if a beneficiary exhibits late symptoms or sequelae of COVID-19, testing would be covered.

It is not covered for general screening in asymptomatic individuals, to determine immunity from past infection, or for return to work/school purposes.

For further guidance on COVID-19 serology/antibody testing, refer to CDC guidance on the proper use of COVID-19 serology testing. The Military Health System (MHS) follows CDC guidelines, while most civilian healthcare plans follow the CARES act.

 

Prescription Monitoring Program (PMP) update

September 17, 2020

The TRICARE Prescription Monitoring Program (PMP) is a quarterly review of beneficiaries receiving prescriptions for controlled substances and has been expanded to include a review of providers issuing prescriptions for controlled substances. Goals of the PMP include identifying beneficiaries who may benefit from additional assistance and education, as well as monitoring provider controlled substance prescribing practices.

Each quarter, the Defense Health Agency (DHA) will provide Humana Military with a list of East Region providers that have written prescriptions for controlled substances. Humana Military will review the report, and reach out to providers for additional information if needed. Humana Military may recommend clinical resources to the prescribing provider with the goal of increasing beneficiary safety and effectiveness of treatment. Find more information on this program in the TRICARE Operations Manual, Chapter 28

A secure, searchable tool is available to network providers through provider self-service

 
 

 

New guidance on telemedicine Intensive Outpatient Programs (IOP) and half-day Partial Hospitalization Programs (PHP)

July 17, 2020

The Defense Health Agency (DHA) has issued new guidance on the use of telemedicine for TRICARE-covered diagnostic and treatment services. Services must be medically or psychologically necessary and appropriate.

IOP guidelines

  • Two to less than six-hour outpatient program taking place in an organized setting, day or evening.

  • Providers may carry out some IOP services via telemedicine (for example, individual psychoeducation, case management, recreational therapy, etc.). Telemedicine does not cover: drug screening, group psychotherapy and some other services.

  • TRICARE policy requires a referral OR prior authorization for IOP care.

  • The IOP or half-day PHP providing services by telemedicine must be at the same intensity and level of service required by those programs per policy. The provider must show they are offering all components of the IOP via telemedicine (e.g., at least two hours of services). IOPs and half-day PHPs must document all services via telemedicine in the medical records and on the claim.

Please note: Full-day (any services lasting six hours or longer), full-intensity PHP services provided under telemedicine are not currently covered.

Billing guidelines

Providers should hold their claims until after August 10, 2020. After August 10, please submit claims using the modifier GT and revenue code 0780.

See the TRICARE Policy Manual, Chapter 7, Section 22.1 for more information.

 
 

 

TRICARE and fetal surgery

July 16, 2020

If a beneficiary under your care requires fetal surgery, Humana Military has a dedicated phone line with case managers standing by to assist. Please contact our Integrated Care Team at (800) 881-9227.

 
 

 

TRICARE updates Skilled Nursing Facility (SNF) admission policy

July 10, 2020

TRICARE follows Medicare requirements for admission to a Skilled Nursing Facility (SNF). For admission to be covered, the beneficiary must have a qualifying hospital stay of at least three consecutive days (not including the hospital discharge day) and be admitted to the SNF within 30 days of hospital discharge.

Effective October 1, 2019, TRICARE adopted the Medicare Interrupted Stay Policy. Medicare defines an interrupted stay as one in which a beneficiary is discharged from a SNF and readmitted to the same SNF during the interruption window, which is a three-day period beginning on the first non-covered day following a SNF stay and ends at 11:59 PM on the third consecutive non-covered day. If these conditions are met, the subsequent stay is considered a continuation of the previous “interrupted” stay for the purposes of both the variable per diem and assessment schedules.

If the beneficiary is readmitted to the same SNF outside the interruption window or to another SNF, regardless of the length of time between stays, the Interrupted Stay Policy does not apply, and the subsequent admission will be considered a “new stay.” In this case, the variable per diem schedule will reset to Day 1 payment rates, and the assessment schedule will reset to Day 1, which will necessitate a new five-day assessment.

See the TRICARE Reimbursement manual, Chapter 8, Section 2 for more information.

 

TRICARE coverage of Continuous Glucose Monitoring Systems (CGMS)

July 9, 2020

  • On January 1, 2020, TRICARE revised its CGMS benefit to allow beneficiaries with uncontrolled diabetes the use of FDA-approved CGMS.

  • TRICARE coverage includes both therapeutic and non-therapeutic devices.

  • Therapeutic CGMS is defined as a device that is approved by the FDA for non-adjunctive use (i.e., used as a replacement for finger stick BGM testing). Therapeutic (non-adjunctive) CGMS and supplies shall be reported utilizing HCPCS codes K0553-K0554 (or subsequent codes if replaced or renumbered). Devices that are labeled for use as therapeutic (non-adjunctive), even if the patient continues to perform glucose self-testing (e.g., finger sticks), shall be reported utilizing these codes.

  • Non-therapeutic CGMS is defined as a device that is approved by the FDA for use to complement, not replace, information obtained from finger stick testing. Adjunctive (non-therapeutic) CGMS and supplies should be reported with A9276 - A9278 (or subsequent codes if replaced or renumbered), with providers reminded of the requirement to use the most appropriate code for the service rendered. Only those devices which are not labeled by the FDA for therapeutic use (i.e., adjunctive, or only labeled to complement but not replace standard blood glucose monitoring) may be reported utilizing these codes.

  • Specific criteria must be met for coverage, as outlined in TPM Chapter 8, Section 5.3. A benefit review determination is available and encouraged for the initial system.

Providers should submit CGMS requests, and attach the Continuous glucose monitor attestation form, online through provider self-service

If you have further questions, please see our frequently asked questions

 

Portable CPAP now covered

July 8, 2020

Under TRICARE’s Durable Medical Equipment (DME) benefit, beneficiaries who have been diagnosed with obstructive sleep apnea syndrome or respiratory insufficiency, may be eligible to receive a Continuous Positive Airway Pressure (CPAP) machine. Prior authorization is required for this limited benefit.

TRICARE may also cover a portable CPAP machine for Active Duty Service Members (ADSM) with a referral that states the beneficiary:

  • has a diagnosis of obstructive sleep apnea

  • travels on official business at least three days per month, or is being deployed

  • is not retiring or separating from the military within the year

Please note:

  • The portable device must have humidification and battery capability.

  • If the beneficiary has a standard CPAP machine, a portable machine is covered if the above conditions are met. TRICARE will not authorize a standard CPAP machine if the beneficiary already has a portable machine.

Billing guidelines:

Please provide a description and bill under Healthcare Common Procedure Coding System (HCPCS) code E1399.

See additional information about TRICARE CPAP machine benefit, conditions and exclusions

 

TRICARE temporarily revises telemedicine benefit

June 17, 2020

As telemedicine continues to play an important role in healthcare, TRICARE has updated its policy on the coverage and expansion of services, costs and other benefits.

May 19, 2020 updated temporary benefits include:

  • Audio-only healthcare visits are now covered

  • No out-of-pocket costs for covered telemedicine services

TRICARE will now waive cost-shares, copayments and deductible (if applicable) for covered telemedicine services from a military provider or TRICARE network provider. This waiver applies to all covered in-network telemedicine services, not just the services related to COVID-19.

More providers able to offer covered telemedicine services

Prior to the stateside public health emergency, TRICARE policy required providers to have a license in the state where they practice and where the patient lives. TRICARE will now reimburse providers for interstate care to patients. The care must be permitted by federal or state licensing laws.

 

TRICARE manuals now include a Patient-Driven Payment Model (PDPM) for Skilled Nursing Facility (SNF) reimbursement

June 9, 2020

Retroactive to October 1, 2019, TRICARE has adopted the Medicare Skilled Nursing Facility (SNF) Prospective Payment System (PPS) payment methods, including Minimum Data Set (MDS) assessments, Patient-Driven Payment Model (PDPM) classifications and Medicare weights and per diem rates.

TRICARE’s PDPM model

Under PDPM, there are six payment components. Five are case-mix adjusted to allow for diagnostic variances and illness severity; the sixth is non-case-mix adjusted and covers SNF resources that do not vary according to beneficiary characteristics.

  • Physical Therapy (PT) – includes a variable per diem factor

  • Occupational Therapy (OT) – includes a variable per diem factor

  • Speech Language Pathology (SLP)

  • Nursing

  • Non-Therapy Ancillary (NTA) services – includes a variable per diem factor

See the TRICARE Reimbursement Manual, Chapter 8, Section 2 for more information.

 
 

 

Physical Therapy Assistants (PTA) and Occupational Therapy Assistants (OTA) are now covered by TRICARE

June 8, 2020

Effective April 16, 2020, TRICARE has approved Physical Therapy Assistants (PTA) and Occupational Therapy Assistants (OTA) as TRICARE-authorized providers under the supervision of a TRICARE-authorized, licensed and registered physical therapist or occupational therapist in accordance with Medicare’s rules for supervision and qualification.

Per TRICARE guidelines, PTAs and OTAs may not:

  • Provide an initial examination

  • Provide an evaluation

  • Provide a re-evaluation and/or assessment

  • Establish a diagnosis

  • Establish a plan of care

When submitting claims, please follow these guidelines:

  • Use the CQ modifier when submitting claims for services performed in whole or in part by a PTA

  • Use the CO modifier when submitting claims for services performed in whole or in part by an OTA

 
 

 

TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement

May 19, 2020

Retroactive to January 1, 2020, TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement. Humana Military will release PDGM-reimbursed HHA claims with dates of service on or after January 1 as soon as system changes are implemented.

TRICARE’s PDGM model

TRICARE’s PDGM reimbursement model closely follows Medicare’s PDGM*.

  • Reimbursement is based on 30-day periods of care vs. 60-day episodes**.

  • Therapy thresholds are no longer used to determine payments. Reimbursement is based on timing, admission source, clinical group, functional impairment level and comorbidity adjustment.

  • Health Insurance Prospective Payment System (HIPPS) codes are still reported with revenue code 0023.

*Unlike Medicare, TRICARE requires a Treatment Authorization Code (TAC). 
**Authorizations for home health services, OASIS assessments and updates to patient care plans remain on a 60-day period of care.

 

Reimbursement

Except for low utilization HHAs, providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim. Providers must bill in non-overlapping 30-day periods of care.

  • For 60-day episodes that began on or before December 31, 2019 and span into 2020, payment will be for the 60-day episode. For 30-day periods of care that start on our after January 1, 2020, reimbursement is based on 30-days.

  • HHAs participating in Medicare prior to January 1, 2019 will continue to receive RAP payments, now a 20/80 split. Those who began participating in Medicare on or after January 1, 2019 will receive an entire payment with the final claim.

  • HHAs with low utilization (two to six visits per 30-day period) will be paid a standardized per visit payment instead of payment for a 30-day period of care.

Medicare updates rates annually on a calendar year basis.

Note: This guidance does not apply to home health services provided to Active Duty Family Members (ADFM) under the Extended Care Health Option (ECHO).

 
 

 

Already-approved referrals and authorizations have been extended 180 days from the expiration date

May 18, 2020

With provider offices across the country rescheduling patient appointments due to the COVID-19 outbreak, we recognize some already-approved authorizations for TRICARE beneficiaries may expire before pandemic restrictions are lifted. In an effort to reduce administrative burden for providers, we have automatically extended certain outpatient referrals and authorizations an additional 180 days. Humana Military has automatically updated the referral/authorization end dates and the updates are reflected in provider self-service.

Key points

  • We have extended already-approved outpatient referrals and authorizations that expire(d) between March 1, 2020 and June 30, 2020. Please note exceptions below.

  • Extensions are for a duration of 180 days from the original expiration date. The number of approved visits did not change.

  • Extensions apply to active duty and non-active duty beneficiaries.

Note: TRICARE eligibility guidelines still apply. As some beneficiaries’ enrollment status may change during the pandemic shutdown, it is important to verify eligibility and benefit coverage prior to rendering services. Any authorization extensions issued do not supersede TRICARE‘s eligibility policies.

Extension exclusions

The following outpatient care types are excluded from the 180-day extension:

  • Active duty Supplemental HealthCare Program (SHCP) waivers

  • Audiology / Hearing aids

  • Autism Care Demonstration (ACD)

  • Behavioral healthcare

  • Department of Veterans Affairs (DVA)/Department of Defense (DoD) Memorandum of Agreement (MOA)

  • Durable Medical Equipment (DME)

  • Hemodialysis

  • Home healthcare

  • Infusions

  • Line of Duty (LOD)

  • Maternity-related services

  • Orthotics/Prosthetics

  • Stem cell transplant

 

TRICARE coverage of Transcutaneous Electrical Nerve Stimulation (TENS) and Dry Needling (DN) has changed

Effective June 1, 2020, TENS units, and the supplies to support the device, will no longer be covered for acute, subacute and chronic Low Back Pain (LBP).

In addition to the device, the following also will not be covered related to a TENS unit:

  • Physical therapy visits, where the sole treatment provided is TENS for LBP, will not be eligible for cost-share

  • Charges for TENS treatment, performed during an otherwise-covered physical therapy visit, will not be eligible for cost-share

See TRICARE Policy Manual Chapter 7, 4.17

Dry Needling (DN) is considered unproven by TRICARE and is therefore not a covered service.

  • If DN is performed during the course of an otherwise-covered physical therapy visit, TRICARE may cost-share the cost of the covered services, but no reimbursement will be allowed for DN

  • Physical therapy visits, where the sole treatment is DN, are non-covered

See TRICARE Policy Manual Chapter 7, 4.18

 
 

 

TRICARE is announcing an exception to policy regarding the use of Telehealth (TH) capabilities for Applied Behavior Analysis (ABA)

March 31, 2020

Attention ABA providers:

TRICARE is announcing an exception to policy regarding the use of Telehealth (TH) capabilities for Applied Behavior Analysis (ABA) services specifically during this COVID-19 pandemic.

During effective dates of March 31, 2020 through May 31, 2020, (“emergency period”), TRICARE is permitting the unlimited use of only CPT code 97156 Parent/ Caregiver Guidance when synchronous telehealth services are used for beneficiaries with a current active authorization. DHA will provide additional guidance should the emergency period extend past May 31, 2020.

  • CPT code 97156, in person or via TH, may be rendered by only Board Certified Behavior Analysts and assistant behavior analysts.

  • CPT Codes 97151, 97153, and 97155 continue to be prohibited for delivery via TH.

  • The contractor shall remove the Medically Unlikely Edit (MUE) only for CPT code 97156 when it is done via TH to allow for the temporary provision of rendering unlimited CPT code 97156 via TH.

  • On any date of service, if the GT modifier is used for CPT code 97156, only 97151 and T1023 shall be payable in addition to 97156/GT. All other CPT codes filed on the same date of services as CPT code 97156/GT shall be denied reimbursement.

  • On any date of services where CPT code 97156 is filed without the GT modifier, all CPT codes in the existing ABA authorization for that beneficiary shall be payable.

  • No additional authorization is required, and no changes to the existing authorization, including expiration dates, will be required of the contractors. Maintaining the current authorization ensures that all submitted claims are tied to an existing authorization, therefore preventing any non-authorized Autism Care Demonstration (ACD) claims from being paid.

  • For new authorizations resulting from new referrals during this unique period, CPT code 97151 will be issued to complete an indirect assessment, review of records and development of a treatment. The treatment plan should be developed with the full recommendation of all CPT codes for the six-month authorization period. Any program modifications may be completed under in-person CPT code 97155 once the social distancing provision is lifted.

  • Should the ABA provider render CPT code 97156 via TH, the claims filed must include the GT modifier and Place of Service code 02 or the claim shall be denied.

  • Every session rendered via 97156 TH shall adhere to the same documentation standards set forth in TOM Chapter 18, Section 4, Paragraph 17.2. to include documenting Place of Services 02.

  • All other criteria defined in TPM Chapter 7, Section 22.1 “Telemedicine” apply including the use of a HIPAA compliant platform, and compliance with all state/country licensing and privileging practice laws.

  • For authorizations that expire during this specified window, the ABA provider may submit CPT code 97151 since much of that time is used for completing the treatment plan update via indirect services. All requirements of CPT code 97151 still apply.

  • No extensions to the authorization timeline will be granted. For authorizations expiring during this period, and subsequent authorization requests, all relevant requirements (i.e., the PDDBI) are expected to be completed on time.

  • No retro-authorizations or extensions to the timeline will be authorized.

  • No other ACD program requirements will be exempt.

Additionally, providers should anticipate longer processing and payment times for claims as this policy exception is being implemented.

The implementation date for this change is March 31, 2020 and the effective date is March 31, 2020.

FAQs are available at Health.mil/autism

 
 

 

Elective procedures in military hospitals/clinics (MTF) and Dental Treatment Facilities (DTF)

March 30, 2020

The Department of Defense (DOD) is directing all military hospitals/clinics and DTFs to immediately postpone all elective surgeries, invasive procedures, and dental procedures performed on beneficiaries with the exceptions outlined below. This includes aerosol-producing procedures, such as endoscopies, bronchoscopies, pulmonary function tests, and sleep Continuous Positive Airway Pressure (CPAP) titrations.

This policy is effective March 31, 2020, and will remain in place for 60 days. This action aligns with actions across the nation to conserve vital healthcare resources during this public health emergency, to include bed space, personal protective equipment, supplies and medical personnel. This policy also protects patients, medical personnel and the community from further exposure and transmission of COVID-19.

The Commanders and Directors of these facilities may authorize surgeries or procedures that can be safely performed at their facility if required to maintain deployability and readiness of Active Duty Service Members (ADSM) including any Reserve component or National Guard member activated or issued a delayed-effective-date active duty order, as provided in 10 U.S.C. 1074(d). The Commanders and Directors may authorize an elective surgery or procedure if, after consulting with the relevant medical or dental specialist, he or she determines the risk to the patient of delaying the surgery or procedure outweighs safety concerns and logistics considerations (e.g. availability of beds, supplies, equipment and medical providers). Any beneficiary whose procedure is cancelled will be contacted through a means that confirms receipt and, to the greatest extent possible, by personal phone call.

As the Military Health System (MHS) prepares for a surge in demand for healthcare services related to COVID-19, it is essential that we take prompt action, informed by local conditions and your risk-benefit analysis. As you take action, we ask that you be mindful of the impact that cancelling or postponing surgery has on our beneficiaries, their families and our professional staff. While their surgeries may be elective, this is nonetheless a meaningful change to their life plans.

 
 

 

Coronavirus Disease (COVID-19) and TRICARE’s telemedicine benefit

April 29, 2020

**Update: Effective April 23, 2020, TRICARE has approved use of telemedicine services to include otherwise-covered behavioral health services during the COVID-19 outbreak.

These services include:

  • Telemental health services, including individual psychotherapy, crisis management, family therapy or group therapy (expected to continue after the coronavirus pandemic)

  • Medication assisted treatment (only during the coronavirus pandemic)

  • Opioid treatment programs (only during the coronavirus pandemic)

  • Intensive outpatient programs, including medication management, case management, recreational therapy, occupational therapy and discharge planning (only during the coronavirus pandemic)

  • Please note: Full-day (any services lasting six hours or longer), full-intensity PHP services provided under telemedicine are not currently covered

We are working diligently to update our claims system to reflect this change.

 
 

March 18, 2020

**Update: If a beneficiary meets all other criteria for a covered service for speech therapy and for continuation of PT/OT, (but not initiation of PT/OT), it is covered using telemedicine, using any coding modifiers as you would for a TRICARE network provider office visit.

 
 

March 17, 2020

The CDC, Department of Defense (DOD) and other government partners are closely monitoring the COVID-19 outbreak while encouraging actions to limit the spread of the virus. Utilizing the telemedicine option is a safe way to treat patients, while containing the spread to medical facilities.

TRICARE covers the use of interactive audio/video technology services, and are subject to the same referral and authorization requirements and include, but are not limited to: clinical consultations, office visits and telemental health.

As a reminder:

  • For TRICARE payment to be authorized, the provider must be TRICARE-authorized and the service must be within a provider’s scope of practice under all applicable state(s) law(s) in which services are provided and or received.

  • Video conferencing platforms used for telemedicine services must have the appropriate verification, confidentiality and security parameters necessary to meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Providers billing for telemedicine services that are:

  • Synchronous* will use CPT or HCPCS codes with a GT modifier for distant site and Q3014 for an applicable originating site to distinguish telemedicine services. Also, Place of Service “POS 02” is to be reported in conjunction with the GT modifier.

  • Asynchronous* will use CPT or HCPCS codes with a GQ modifier.

*Synchronous telemedicine services involve an interactive, electronic information exchange in at least two directions in the same time. Asynchronous telemedicine services involve storing, forwarding and transmitting medical information on telemedicine encounters in one direction at a time.

Applied Behavior Analysis (ABA) providers:

  • The TRICARE Operations Manual, Autism Care Demonstration (ACD) specifies that with the exception of completing outcome measures, the ACD does not permit for telemedicine (paragraph 8.2.2). Telemedicine is not covered for ABA services billed under CPT codes 97151, 97153, 97155 or 97156.

When submitting claims for telemedicine services, the provider may indicate "Signature not required – distance telemedicine site" in the required patient signature field. ABA providers submitting claims for outcome measures administered via telehealth must include the modifier GT.

Visit telemedicine services or TRICARE Policy Manual, Chapter 7, Section 22.1 for more information.

 
 

 

Breast milk bag modifier has changed

March 9, 2020

On January 1, 2020, Centers for Medicare and Medicaid Services (CMS) released a new Healthcare Common Procedure Coding System (HCPCS) code for use on breast milk storage.

  • Providers should use HCPCS code: K1005 for breast milk bag claims filed beginning on 1/1/2020.

  • Providers should use HCPCS codes: A9900 or A9999 using modifier –XH for breast milk bag claims filed prior to 1/1/2020.

If providers do not bill to the updated HCPCS code K1005 for claims after 3/1/2020, the claims will reject.

As a reminder, TRICARE allows 90 breast milk bags, every 30 days following a birth event. Providers must bill for the actual number of milk bags supplied (90), and not for a single (one) box of breast milk bags to get paid correctly.

Visit breast milk supplies for more information.

 
 

 

Home Health Agency (HHA) code update

March 9, 2020

In 2016, a new purchasing demonstration for Home Health Agencies (HHA) was introduced in five East Region states: Florida, Maryland, Massachusetts, North Carolina and Tennessee. The Home Health Value-Based Purchasing Model (HHVBP) offers incentives to any HHAs who give higher quality and more efficient care. The Defense Health Agency (DHA) is currently working on a new HHVBP Demonstration and a Patient-Driven Groupings Model (PDGM).

While the new codes are available for use, the new reimbursement information has not been released. To prevent providers from having to resubmit, we are holding claims until DHA updates the information.

If providers use the old code, the system will generate an error and claims will not process. If the new code is used, we will hold these claims until DHA releases the new pricing.

For more information, visit HHVBP Adjustments and review the CMS’ FAQs

 
 

 

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