Cancer and Children’s Hospitals Move to Outpatient Prospective Payment System Billing on Oct. 1

Tuesday, September 26, 2023

Per the Defense Health Agency (DHA), outpatient services provided by cancer and children's hospitals will be subject to the TRICARE Outpatient Prospective Payment System (OPPS) for services dates on or after Oct. 1, 2023. Previously, cancer and children’s hospitals were exempt from OPPS billing. Find complete details in the TRICARE Reimbursement Manual (TRM), Chapter 13. You can look up OPPS reimbursement rates at https://health.mil/rates.

We offer answers to frequently asked questions to help facilities prepare for this change. Find additional FAQs on our billing tips page.

Will children or cancer hospital network agreements be amended?
We do not anticipate any changes to network agreements because of this change.

Will facilities need to change their billing programs?
There are no additional claim form fields when billing an OPPS claim. Facilities will need to bill in accordance with TRM, Chapter 13. 

Is there still a transitional OPPS payment (TOP)?
With cancer and children’s hospitals moving to OPPS, these facilities may be eligible for hold-harmless payments every year. Hold-harmless payments are based on cost-to-charge ratios instead of the payment-to-cost ratio. Learn more about this annual payment on our billing tips page.

Will the blended rate for hospital outpatient radiology claims still apply?
Effective Oct. 1, 2023, cancer and children’s hospitals will no longer be paid using the blended rate for outpatient radiology claims. Instead, they will be subject to OPPS. For radiology services that Medicare excludes from OPPS, payments will be based on the CHAMPUS Maximum Allowable Charge.

How are facilities paid General Temporary Military Contingency Payment Adjustments (GTMCPA)? Do facilities have to request these?
DHA may approve a GTMCPA payment for hospitals that serve a disproportionate share of active duty service members and active duty family members. Find details on how to request GTMCPA payments from DHA and how to determine a TRICARE patient’s military status on our billing tips page. Please review TRM, Chapter 13 for complete details.