TRICARE has completed its significant effort to customize an outpatient payment system to meet the unique needs of its population. It is based on the Medicare Ambulatory Payment Classifications (APC) system, and created with the assistance of 3M Health Information Systems. The new TRICARE outpatient prospective payment system (OPPS) precisely accounts for services provided to TRICARE beneficiaries for hospital outpatient services, beginning May 1, 2009.
The 3M APCfinder Software for TRICARE is a grouper with functionality similar to the market leading 3M APCfinder Software. It incorporates the TRICARE-refined APC grouping logic, customized outpatient code editor (OCE) algorithms and agency-specific reimbursement formulae including appropriate fee schedule payments.
For more information, call 800.367.2447 or click here.
Grouping Logic
Some of the refinements to the grouping logic that TRICARE has made include:
- Creation of TRICARE-specific alpha-numeric groupings
- Creation of unique TRICARE status indicators
- Groupings for maternity observation
- Reassignment of many Medicare non-covered services for TRICARE beneficiaries
Editing
TRICARE leadership customized the OCE edits to make certain they were consistent with services rendered to its beneficiaries to include:
- Modified, specific OCE edit logic for consistency with plans
- Deleted edits that did not apply
- Added TRICARE-specific edits to address specific needs
In addition to the TRICARE OCE edits, 3M has added significant additional editing capability to assist users in making certain claims are complete, clean and compliant prior to submission. This decreases the risks of payment delays, and loss of revenue.
Reimbursement
To assist hospitals in determining expected revenues for forecasting, analysis, and validation of payments, 3M APCfinder Software for TRICARE includes payments for standard TRICARE APC logic, including outlier and pass-through payments, as well as payments for fee schedules that include:
- CHAMPUS maximum allowable charge (CMAC) for most labs, therapies, mammography services, etc.
- DME
- Injectables and immunizations
- PEN
- Statewide prevailing charges (items with no CMS established fee adopted by TRICARE)
- Birthing center rates
The 3M solution for TRICARE APC grouping
3M APCfinder Software for TRICARE is a component of the 3M™ Coding and Reimbursement System suite of solutions.
APC software solutions for TRICARE fact sheet
For more information, call 800.367.2447 or click here.