View the TRICARE (Outpatient) Expected Reimbursement Detail

Use the following procedure to view the expected reimbursement detail for TRICARE Outpatient accounts with the Non-OPPS logic applied.

Note: For more information about the TRICARE OP reimbursement terms, refer to TRICARE Outpatient (OP) Tab.

  1. Access the Expected Reimbursement Detail page for a TRICARE Outpatient account. For more information, refer to View the Expected Reimbursement Details .
  2. Review the expected reimbursements.

The following table describes the fields on the Expected Reimbursement Detail page for TRICARE Outpatient claims when the Non-OPPS logic is applied. For internal users only, the source information is given for some fields, in the format: “Table.Field.”

Field

Description

Allowed Percent

Allowed percent as pertains to MSA

Allowed Units

Number of units allowed by reimbursement logic

Billed Charges

Amount billed by the provider for the line item

Billed Units

Number of units billed for the line item

Source: UB-92, FL46; UB-04, FL46

Code Type

Type of code:

  • S – Surgical Code
  • I – Injectable Code
  • C – CMAC Code
  • N – No Pay Government Code
  • A – Ambulance Code
  • W – State Prevailing CMAC Code
  • V – State Prevailing Surgical Code
  • T – Transplant Donor
  • P – Psych

CPT/HCPC Codes & Modifiers

Associated CPT or HCPC codes and modifiers

Source: UB-92, FL44; UB-04, FL44

Error Code

Reason for rejection or return (claim level), if applicable

Source: BILLMCAD.ERRCODE

Expected Payment

The calculated reimbursement for the line item, based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data

Source: Billmast.EXPPAY

Fee Schedule Payment

Total reimbursement from a fee schedule (Lab, DMEPOS, PEN and therapies)

MSA Payment

Metropolitan Statistical Area (MSA) payment for grouped surgical procedures

No.

Sequential reference number of the line item

Other Payment

Non-fee schedule payments (percent of charges)

Pass-Through Payment

Total reimbursement for certain high-cost items like implants, high cost drugs and biologicals for which the actual or higher cost is passed through to the payor. NOTE: This field will be blank for true TRICARE.

Rate

Fee schedule rate

Reason Code

Reason a specific line item was denied or description of how it was paid

Reimbursement Type

Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs)

Rev Code

Revenue code

Source: UB-92, FL42; UB-04, FL42

Service Date

Date the service was rendered

Source: UB-92, FL45; UB-04, FL45

Total Expected Reimbursement

Total expected reimbursement on the claim