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:
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).