Skip to main content

Rates of pay for a provider of care or services furnished under TRICARE program

Division A · Title VII: Health Care Provisions · Subtitle B: Health Care Administration

Plain-language summaryAI

The law requires the Department of Defense to set specific payment rates for healthcare providers under the TRICARE program based on the actual site where care is given, such as hospital outpatient departments, surgical centers, or physician offices. Each care site must have a unique identifier, and claims for payment must include this identifier to be processed. These rules will take effect starting January 1, 2028.

AI-generated from this section’s text — a quick orientation, not a substitute for the full text below. Not legal advice.

Section Text · Sec. 736.
Source →PrevNext

(a) Rates

Section 1097b(a) of title 10, United States Code is amended—

(1)

in paragraph (1), by inserting and paragraph (3)(A) after Subject to paragraph (2) ; and

(2)

in paragraph (3), by striking In establishing and inserting the following

(A)

The Secretary shall establish rates for payments to providers of care or services under the TRICARE program that are specific with respect to the following sites of service at which the care or service is actually provided (regardless of the physical location of the headquarters of the provider):

(i)

A hospital outpatient department.

(ii)

An ambulatory surgical center.

(iii)

The office of a physician.

(iv)

Such other sites as the Secretary determines appropriate in carrying out this paragraph.

(B)

The Secretary shall ensure that—

(i)

each site specified in subparagraph (A) obtains a National Provider Identifier pursuant to section 1833(t) of the Social Security Act ( 42 U.S.C. 1395l(t)(23) ) that is separate and unique from such identifier for such provider; and

(ii)

no payment for care or services under any provision of this chapter may be made unless the claim for such payment includes the National Provider Identifier for the site at which such hospital care, medical services, or extended care services were furnished.

(C)

In the case of covered OPD services (as defined in section 1833(t)(1)(B) of the Social Security Act ( 42 U.S.C. 1395l(t)(1)(B) ) that are provided by a provider that is an off-campus outpatient department of a provider (as defined in section 1833(t)(21)(B) of the Social Security Act ( 42 U.S.C. 1395l(t)(21)(B) ), disregarding clauses (ii) and (iv) thereof, as if such clauses did not exist), the Secretary shall ensure that such department is treated as a subpart of such provider and assigned a unique health identifier pursuant to subparagraph (B) of this paragraph, and that such provider includes such identifier on any claim form it submits under this subsection, and that such provider may not hold a member of the uniformed services or covered beneficiary liable for such item or service unless such care or services are billed using the separate unique health identifier established for such department under this paragraph.

(D)

Nothing in this paragraph may be construed to—

(i)

prevent the Secretary from determining the appropriate amount of a facility fee;

(ii)

require the Secretary to pay, for the same item or service—

(iii)

affect the authority of the Secretary under paragraph (2).

(E)

In establishing

(b) Effective date

The amendments made by subsection (a) shall take effect on January 1, 2028.