TRICARE Operations Manual 6010.62-M, April 2021
Supplemental Health Care Program (SHCP)
Chapter 17
Section 2
ProvidersOf Care
Copyright:CPT only © 2006 American MedicalAssociation (or such other date of publication of CPT).All Rights Reserved.
Revision:
1.0GENERAL
1.1The SHCPpayment structure applies to inpatient and outpatient medical claimssubmitted by civilian institutions, individual professional providers,suppliers, pharmacies, and other TRICARE-authorized providers for CivilianHealth Care (CHC) rendered to Uniformed Service members and otherSHCP-eligible individuals.
1.2The contractor shall referto network providers in accordance with Chapter 1, Section 3 forMarket/Military Medical Treatment Facility (MTF)-referred care.
1.3For carethat is not Market/MTF referred (including care for Market/MTF enrollees),most patients covered by this Chapter will have undergone medicalcare prior to any contact with the Specified Authorization Staff(SAS) (Addendum A) or the contractor.
1.4The contractorshall issue authorizations and assist in finding network providerswhen the patient initiates contact prior to treatment and the SAShas authorized the care being sought; if a network provider is not available,the referral will be made to a TRICARE-authorized provider.
1.5The contractorshall, upon receiving an episode of care authorization from theSAS, record and enter the authorization to enable appropriate claimsprocessing.
1.5.1The contractor shall, if needed,assist the patient with locating a network provider or TRICARE-authorizedprovider (if available) for service determined eligible patientsother than active duty (e.g., Reserve Officer Training Corps (ROTC),Reserve Component (RC)), foreign military).
1.5.2The contractorshall assist patients requesting a provider change if this occursduring an episode of care authorization period. Patients will notbe referred to SAS. No requirement exists for SAS to create a newcare authorization.
1.6Claimsfor active duty dental services in the 50 United States (US), theDistrict of Columbia, and US territories and commonwealths willbe processed and paid by the Active Duty Dental Program (ADDP) contractor.
1.7The contractorshall process and pay claims for adjunctive dental care (or theTRICARE Overseas Program (TOP) contractor for overseas care).
2.0UNIFORMEDSERVICES FAMILY HEALTH PLAN (USFHP)
2.1The contractormay, in addition to receiving claims from civilian providers, receiveSHCP claims from certain USFHP Designated Providers (DPs). The provisionsof the SHCP will not apply to services furnished by a USFHP DP ifthe services are included as covered services under the currentnegotiated agreement between the USFHP DP and the Defense HealthAgency (DHA) (this includes care for a USFHP enrollee).
2.2The contractorshall pay for any services not included in the USFHP DP agreementin accordance with the requirements in this chapter.
2.3The USFHP, administered bythe DPs listed below, currently have negotiated agreements whichprovide the Prime benefit (inpatient and outpatient care). Sincethese facilities have the capability for inpatient services, DPscan submit claims which will be paid in accordance with applicableTRICARE reimbursem*nt rules under the SHCP:
•CHRISTUS Health, Houston, TX(which also includes):
•St. Mary’sHospital, Port Arthur, TX
•St. JohnHospital, Nassau Bay, TX
•St. JosephHospital, Houston, TX
•Martin’s Point Health Care,Portland, ME
•Johns Hopkins Health Care Corporation,Baltimore, MD
•Brighton Marine Health Center,Boston, MA
•St. Vincent’s Catholic MedicalCenters of New York, New York City, NY
•Pacific Medical Clinics, Seattle,WA
3.0DEPARTMENTOF VETERANS AFFAIRS/VETERANS HEALTH ADMINISTRATION (DVA/VHA)
The contractor may, in additionto receiving claims from civilian providers, receive SHCP claimsfrom the DVA/VHA. The provisions of the SHCP will not apply to servicesprovided under any Memorandum of Agreement (MOA) for sharing betweenthe Department of Defense (DoD) (including the Army, Air Force,Navy/Marine Corps, and Coast Guard facilities) and the DVA/VHA.Claims for these services will continue to be processed by the Services.
3.1The contractorshall, for any services not included in any MOA described below,pay claims in accordance with the TRICARE Reimbursem*nt Manual (TRM)to include claims referred for beneficiaries on the Temporary DisabilityRetirement List (TDRL).
3.2Claimsfor Care Provided Under the National DoD/DVA/VHA MOA for SpinalCord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,and Polytrauma
3.2.1The contractor shall processDVA/VHA submitted claims for eligible Service members’ treated under theMOA in accordance with this chapter (SCI, TBI MOA; see Addendum C for a full text copy of the MOAfor references purposes only).
3.2.2The contractorshall process claims received from a DVA/VHA health care facilityfor eligible Service member care as an MOA claim based upon theDefense Health Agency-Great Lakes (DHA-GL) SAS authorization number.
3.2.2.1As determined by SAS, all medicalconditions shall be authorized and paid under this MOA if a conditionof TBI, SCI, Blindness, or Polytrauma exists for the patient.
3.2.2.2The authorization shall clearlyindicate that the care has been authorized under the SCI, TBI, Blindness,and Polytrauma MOA.
3.2.2.3The authorization shall specifytype of care (e.g., inpatient, outpatient) to be given under the referencedMOA and limits of the authorization (e.g., inpatient days, outpatientvisits, expiration date).
3.2.2.4Suggested authorization languageto possibly include “all care authorized under the SCI, TBI, Blindness,and Polytrauma MOA” for inpatient, outpatient and rehabilitativecare.
3.2.2.5SAS shall send authorizationsto the contractor either by fax or by other mutually agreed upon modality.
3.2.3The contractor shall verifywhether the DVA/VHA-provided care has been authorized by the SAS.
3.2.4The contractorshall process the claim to payment if an authorization is on file.
3.2.5The contractorshall not deny claims for lack of authorization. If a required authorizationis not on file, the claim will be placed in a pending status.
3.2.6The contractorshall forward the appropriate documentation to the SAS identifyingthe claim as a possible MOA claim for determination (following theprocedures in the TRICARE Systems Manual (TSM), Chapter1 for the SAS referral and review procedures).
3.2.7The contractorshall pend claims to the SAS for payment determination for any DVA/VHAsubmitted claim for an eligible Service member with a TBI, SCI,blindness, or polytrauma condition that does not have a matchingauthorization number.
3.2.8The contractor shall reimburseMOA claims as follows:
3.2.8.1The contractor shall pay claimsfor inpatient care using DVA/VHA interagency rates, published inthe Federal Register. The interagency rate is a dailyper diem to cover inpatient stays and includes room and board, nursing,physician, and ancillary care. These rates will be provided to thecontractor by DHA (including periodic updates as needed). Thereare three different interagency rates to be paid for rehabilitationcare under the MOA. The Rehabilitation Medicine rate will applyto TBI care. Blind rehabilitation and SCI care each have their own separateinteragency rate. Additionally, it is possible that two or moreseparate rates will apply to one inpatient stay. All interagencyrates except the outpatient interagency rate in the Office of Managementand Budget (OMB) Federal Register Notice provided byDHA will be applicable.
3.2.8.1.1The contractor shall pay theclaim using the separate rates if the DVA/VHA-submitted claim identifiesmore than one rate (with the appropriate number of days identifiedfor each separate rate) (e.g., a stay for SCI may include days paidwith the SCI rate and days billed at a surgery rate.)
3.2.8.1.2The contractor shall verifythe DVA/VHA billed rate on inpatient claims matches one of the interagencyrates provided by DHA.
3.2.8.1.2.1The contractor shall not developDVA/VHA claims for inpatient care submitted with an applicable interagencyrate any further (e.g., for revenue codes, diagnosis) if care hasbeen approved by the DHA/SAS.
3.2.8.1.2.2Claims without an applicableinteragency rate shall be denied and an Explanation of Benefits (EOB)shall be issued to the DVA/VHA, but not the beneficiary. The claimwill need to be resubmitted for payment.
3.2.8.2The contractor shall pay claimsfor outpatient and ambulatory surgery professional services at the appropriateTRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC))with a 10% discount applied.
3.2.8.3The contractor shall pay DVA/VHAclaims at billed charges for services without a TRICARE allowable rate.
3.2.8.4The following care services,irrespective of health care delivery setting require authorizationfrom SAS and are reimbursed at billed charges (actual DVA/VHA cost)separately from DVA/VHA inpatient interagency rates, if one exists:
•Transportation
•Prosthetics
•Non-medical rehabilitativeitems
•Durable Equipment (DE) andDurable Medical Equipment (DME)
•Orthotics (including cognitivedevices)
•Routine and adjunctive dentalservices
•Optometry
•Lens prescriptions
•Inpatient or outpatient TBIevaluations
•Special diagnostic procedures
•Inpatient or outpatient polytraumatransitional rehabilitation program
•Home care
•Personal care attendants
•Conjoint family therapy
•Ambulatory surgeries
•Cognitive rehabilitation
•Extended care including nursinghome care
3.2.8.5The contractor shall processall claims received on or after this date using the guidelines established underthe updated MOA regardless of the date of service. All TRICARE EncounterData (TED) records for this care shall include Special ProcessingCode (SPC) 17 - DVA/VHA medical provider claim.
3.2.8.6If paid at per diem rates,the provisions of Chapter 8, Section 2,apply when enrollment changes in the middle of an inpatient stay.If enrollment changes retroactively, prior payments will not berecouped.
3.3Claims for Care Provided Underthe National DoD/DVA/VHA MOA for Payment for Processing DisabilityCompensation and Pension Examinations (DCPE) in the Integrated DisabilityEvaluation System (IDES)
3.3.1The contractor shall reimbursethe DVA/VHA for services provided under the current national DoD/DVA/VHAMOA for “Processing Payment for Disability Compensation and PensionExaminations in the Integrated Disability Evaluation System” (IDESMOA; see Addendum B for a full text copy of the MOAfor reference purposes only).
3.3.2The contractorshall process claims under the IDES MOA in accordance with thischapter and the following:
3.3.2.1Claims submitted by any DVA/VHAfacility/provider for an eligible Service member’s care with the CurrentProcedural Terminology (CPT) code of 99456, International Classificationof Diseases, 9th Revision (ICD-9) Diagnostic code of V68.01, orInternational Classification of Diseases, 10th Revision (ICD-10)diagnostic code of Z02.71 (Disability Examination) shall be processedas an IDES MOA claim. IDES MOA claims are SHCP claims.
3.3.2.2The contractor shall considerthe referral as a blanket authorization to process claims from anybilling DVA/VHA facility or provider for authorized/DCPE exams andassociated ancillary services under the IDES MOA, although the Market/MTFreferral will specify a particular DVA/VHA facility/provider toprovide the IDES MOA services.
3.3.2.3The Market/MTF will generatea single referral and submit the referral to the contractor. TheMarket/MTF will complete the referral as described in Chapter 7, Section 5.
3.3.2.4The referral will specify thetotal number of Compensation and Pension (C&P) examinations authorizedfor payment by the contractor. It is not necessary for the referralto identify the various specialists who will render the differentC&P examinations. The reason for referral will be entered bythe Market/MTF as “DVA/VHA only: Disability Evaluation System(DES) C&P exams for fitness for duty determination - total.”
3.3.3The DVA/VHAwill list one C&P examination (CPT code 99456) per the appropriatefield of the claim form and indicate one unit such that there isa separate line item for each C&P examination.
3.3.4Relatedancillary services may be billed on the same claim form or on aseparate claim form identified by the single diagnosis of ICD-9/ICD-10diagnostic code, V68.01/Z02.71 (Disability Examination).
3.3.5The contractorshall process the claim to payment (refer to paragraph 2.3) if an IDESMOA claim is received from the DVA/VHA (paragraph 3.2.1) and an authorizationto any DVA/VHA provider is on file). One C&P examination feewill be paid for each referred and authorized C&P examinationup to the total number of C&P examinations authorized by thereferring Market/MTF.
3.3.6The contractor shall verifythat the claim contains CPT code 99456 or ICD-9/ICD-10 code V68.01/Z02.71, andprocess the claim to payment, if an IDES MOA claim is received fromthe DVA/VHA (paragraph 3.2.1) and no authorization is onfile.
3.3.7The contractor shall processall claims for C&P exams as SHCP using the pricing provisionsagreed upon in the IDES MOA. CPT code 99456 shall be used and willbe considered to include all parts of each C&P examination, exceptancillary services.
3.3.8Claims for related ancillaryservices shall be paid at the appropriate TRICARE allowable rate(e.g., CMAC) with a 10% discount applied.
| Effective Date | C&P Disability Exam (99456) | ancillary services |
|---|---|---|
| 01/01/2011 | $515.00 | CMAC - 10% |
3.3.9The contractor’s TED recordsfor this care shall include SPC DC (C&P Examinations-DVA/VHA),SPC 17 (VA Medical Provider Claim), and EnrollmentHealth Plan Code SR (SHCP-Market/MTF Referred Care).
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