TRICARE Outpatient (OP) Tab

The OP tab on the TRICARE Term Reimbursement editor defaults to the default settings for how the federal regulations say it should pay. The Apply Non-OPPS Logic check box at the top of the OP tab allows you to define whether Non-OPPS edits should be applied. This check box also determines the fields that are available on the tab.

Note: Refer to the contract to determine the options to select and the values to enter.

Field Descriptions

The following table describes the fields on the OP tab of the TRICARE node.

Field	Description
Apply Non-OPPS logic	Determines whether the Non-OPPS logic is applied and controls which fields on the reimbursement tool are available
National
Override MSA Grouper	Provides the option to override MSA Groupers
Apply Lesser of Fee Schedule or % of charges	Provides the option to apply the lesser of the fee schedule amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
OP Surgery Method 2	Provides the option to override the percentage of charges reimbursed for TRICARE Non-OPPS Surgical lines identified as Method 2 surgeries.
Override Implants	Provides the option to override the reimbursement percentage for implant revenue codes 274-276, 278, and 279 for all outpatient surgical claims. Select the following as applicable and enter the appropriate percentage: Billed Charge State Prevailing Charge
Override Rev 45x	Provides the option to override the percentage for revenue codes beginning with “45.”
Override Rev 51x	Provides the option to override the percentage for revenue codes beginning with “51.”
Override Rev 76x	Provides the option to override the percentage for revenue codes beginning with “76.”
Override Blood Products	Provides the option to override the reimbursement percentage for blood products (revenue codes 380-390)
Override Transplant Donor	Provides the option to override transplant donor charges by a specified percentage
Replace Questionable Covered Services with	Provides the option to have Questionable Covered Services priced using either of the following methods instead of billed charges: Fee Schedule Zero
CMAC Fee Schedule
Override % of	Percentage of Fee Schedule or charges
Apply Lesser of Fee Schedule or % of charges	Provides the option to apply the lesser of the fee schedule amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
When code not found	Percentage to reimburse when a code is not found in the fee schedule
Region
Apply Regional Logic	Provides the option to activate the State Prevailing CMAC Fee schedule.
Override State Prevailing Surgery	Provides the option to override the regional surgical groupers.
State Prevailing CMAC Fee Schedule
Override % of	Percentage of the State Prevailing CMAC Fee Schedule or charges
Apply Lesser of Fee Schedule or % of charges	Provides the option to apply the lesser of the fee schedule amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
Ungrouped Surgery Percentage
Override % of charges	The percent of billed charges paid for ungrouped surgical procedures. Typically, this option is only selected for managed care contracts. This option should only be used when non-grouped surgery is listed in the contract as a case rate. No other services other than surgeries will be reimbursed.
SCH
Override SCH % of charges	Provides the option to price based on a percentage of charges for Sole Community Hospitals.
Psych
Per Diem	Percentage of per diem charges
Global
Truncate (do not round) total	Provides the option to truncate the total. For example if a total is 100.85, it is truncated to 100. If left unchecked, the total will round to 101.
Do not consume units	Provides the option not to consume units. This is used for contract carve outs.
Do not consume charges	Provides the option not to consume charges. This is used for contract carve outs.
Component Percentages
Pass-through Amount	Pass-through percentage amount that affects only APC payments (not fee schedule payments); allowable range is 0 to 500
Apply Lesser of Pass-through or % of charges	Provides the option to apply the lesser of the pass-through amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
APC Amount	APC percentage amount that affects only APC payments (not fee schedule payments); allowable range is 0 to 500
Apply Lesser of APC or % of charges	Provides the option to apply the lesser of the APC amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
Outlier Amount	Outlier percentage amount that affects only APC payments (not fee schedule payments); allowable range is 0 to 500
Fee Schedule
Override % of	Percentage of the fee schedule or charges that is paid; allowable range is 0 to 500
Apply Lesser of Fee Schedule or % of charges	Provides the option to apply the lesser of the fee schedule amount or a designated percentage of charges. Typically, this option is only selected for managed care contracts.
Other
Replace zero payment (error) with	Percentage of the total claim that is paid when nothing on the claim is payable under APCs or a fee schedule. If at least one service type is reimbursed, this option is bypassed.
Replace blank date with service to date	Provides the option to replace a blank service date with the service to date.
Ignore CCI Edit 039	When selected, the system overrides edit 039 and prices the line item. Edit 039 indicates that the line item is not payable because it is mutually exclusive to another line item on the claim.
Cancel Modifier 25 error	When selected, indicates that the contract pays all charges, regardless of whether there is both a procedure and physician visit.
Ignore CCI Edit 040	When selected, the system overrides edit 040 and prices the line item. Edit 040 indicates that the line item is not payable because it is part of another line item on the same claim.
Show denied totals	Provides the option to show all denied totals.
Ignore TRICARE device code edit	Ignores the device code edit so it is not applied to claims repriced by this reimbursement tool. The device code edit requires the identification of the implant device in most implant cases. This check box defaults to unselected, indicating the edit is active, but most managed care plans do not require this edit.
Ignore TRICARE service to and service from date rule	Ignores the TRICARE service to and service from date rule.
Override Network Provider Indicator	Allows a facility to override the Network Provider Indicator and set up two profile types: Contracted Non-contracted Note: This field defaults to Blank.