Outpatient Prospective Payment System (OPPS)

TRICARE OPPS is mandatory for both network and non-network providers and applies to all hospitals participating in the Medicare program with some exceptions (e.g., Critical Access Hospitals (CAH), cancer hospitals and children’s hospitals).

TRICARE OPPS also applies to hospital-based Partial Hospitalization Programs (PHP) subject to TRICARE’s prior authorization requirements and hospitals (or distinct parts thereof) that are excluded from the inpatient DRG-based payment system to the extent the hospital (or distinct part thereof) furnishes outpatient services. Several organizations, as defined by TRICARE policy, are exempt from OPPS:

  • CAHs
  • Certain hospitals in Maryland that qualify for payment under the state’s cost containment waiver
  • Hospitals located outside one of the 50 United States, Washington, D.C. and Puerto Rico
  • Indian Health Service hospitals that provide outpatient services
  • Specialty care providers, including:
  • Cancer and children’s hospitals
  • Community behavioral health centers
  • Comprehensive outpatient rehabilitation facilities
  • VA hospitals
  • Freestanding Ambulatory Surgery Centers (ASC)
  • Freestanding birthing centers
  • Freestanding end-stage renal disease facilities
  • Freestanding PHPs (psychiatric facilities and Substance Use Disorder Rehabilitation Facilities [SUDRF])
  • Home Health Agencies (HHA)
  • Hospice programs
  • Other corporate services providers (e.g., freestanding cardiac catheterization and sleep disorder diagnostic centers)
  • Skilled Nursing Facilities (SNF)
  • Residential Treatment Centers (RTC)

TRICARE allowable charge/CMAC fee schedule pricing, including injectable rates on payable claim lines not grouped to an APC, are updated on a quarterly basis. Annual TRICARE allowable charge/CMAC rates generally available and effective February 1 have a two month lag under OPPS (i.e., April 1 instead of February 1).

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