What are the TRICARE filing and reimbursement guidelines?

Per TRICARE Reimbursement Guidelines, TRICARE authorizes contractors of managed care support contracts to reimburse hospitals for allowed Capital and DME Costs. Instructions can be found at the following location: TRICARE Cost Report CAP DME

Filing Guidelines

  • Any hospital subject to the TRICARE Diagnostic Related Groups (DRG)-based payment system, which wishes to be reimbursed for allowed Capital and DME Costs, must submit a request for reimbursement to the TRICARE contractor.
  • The initial request must be submitted on or before the last day of the twelfth month following the close of the hospital’s cost-reporting period. The request must correspond to the hospital’s Medicare cost reporting period (dates and costs). Hospitals must submit their request forms and applicable pages from their Medicare cost reports to the TRICARE contractor. Those hospitals that are not Medicare participating providers are to use October 1 through September 30 fiscal year for reporting Capital and DME costs.
  • All amended requests as a result of a subsequent Medicare desk review, audit, or appeal must be submitted along with a copy of the Notice of Program Reimbursement (NPR) and the applicable pages from the amended Medicare Cost Report to the TRICARE contractor within 30 days of the date the hospital is notified of the change. Failure to promptly report the changes resulting from a Medicare desk review, audit, or appeal is considered a misrepresentation of the cost report information. Such a practice can be considered fraudulent, which may result in criminal/civil penalties or administrative sanctions of suspension or exclusion as an authorized provider.

Reimbursement Guidelines

  • The total Allowable Cost portion is composed of Capital and DME costs reported Medicare Cost Report
  • The ratio of TRICARE IP days to Total IP days is calculated and applied to Total Allowable Costs to determine Capital and DME payment

 

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