The following resources provide payment information related to TRICARE and Veterans' Affairs payment.
For additional assistance with payment and reimbursement issues, contact APTA's Payment Policy & Advocacy department at 800/999-2782, ext 8511 or email@example.com.
Information on Veterans' Care by Non-VA Providers
Medical care can be provided to eligible veterans outside of the Department of Veterans Affairs (VA) when VA medical facilities are not "feasibly available." If a veteran is eligible for certain medical care, the local VA hospital or clinic should provide it as the first option. If it can't, then each local VA medical facility has criteria to determine whether non-VA care may be used.
Two non-VA provider programs are the Veterans Choice Program and Patient-Centered Community Care (PC3) contracts.
Veterans Choice Program (VCP)
Under the VCP, Veterans must receive prior authorization from VA to receive care from one of VA's VCP network of community providers. The authorization is based on specific eligibility requirements and discussions with the veteran's VA provider. VA must authorize care that is needed beyond the scope of the first authorization. Veterans may be eligible to receive care through the Veterans Choice Program based on 1 or more of the following conditions:
- VA can't provide the services the veteran needs.
- VA can't make an appointment for the veteran at the nearest VA medical facility within 30 days of the clinically indicated date (the date the veteran and his or her VA provider agree should be the next date the veteran is seen for care), or if VA can't determine this date, the date the Veteran prefers to be seen next.
- The veteran lives more than a 40-mile drive from the nearest VA medical facility with a full-time primary care physician.
- The veteran has to travel by air, boat, or ferry to get to the nearest VA medical facility.
- The veteran faces an excessive burden in traveling to the nearest VA medical facility (such as geographic challenges, environmental factors, or a health problem that makes it hard to travel).
The Veterans Choice Program is administered by TriWest Healthcare Alliance and Health Net Federal Services. Health Net's contract will expire effective September 30, 2018, but it is unclear at this point what contractor will take over.
Additional Veterans Choice Program Resources:
Patient-Centered Community Care (PC3) Contracts
When a veteran requires primary and specialty care that is not readily available at his or her VA health care facility (HCF), the HCF may use a Patient-Centered Community Care (PC3) contract to purchase the veteran's care. The HCF's clinical and Non-VA care teams coordinate to determine if the care is available at the HCF, a different nearby HCF, or another health care partner. If not, they will look to the PC3 contractor to buy the care.
Currently, the PC3 contractors are TriWest Healthcare Alliance and Health Net Federal Services. Health Net's contract will expire effective September 30, 2018, but it is unclear at this point what contractor will take over.
Additional PC3 Resources:
Additional Veterans Affairs Resources
The TRICARE program is administered by 2 separate contractors in 2 different regions: the East Region is administered by Humana Military. The West Region is administered by Health Net Federal Services.
PTAs and TRICARE: Update
June 6, 2018: The National Defense Authorization Act of 2017, signed on December 12, included a provision adding PTAs (and OTAs) as authorized providers under TRICARE. However, this change is not yet effective. The change to regulation will be implemented through the notice and comment rulemaking process. The proposed rule is expected in the fall of 2018 or spring of 2019. A 60-day comment period will follow the release of the proposed rule, after which the Department of Defense will review the comments and draft and publish the final rule.
Until the rule is finalized and published, TRICARE does not consider a PTA as an authorized provider, and the rule will not be retroactive.
APTA will keep members informed of the timeline for this changeover to the TRICARE system.
Additional TRICARE Resources
APTA Managed Care Contracting Toolkit: This can be a helpful resource when contracting with managed care contractors such as those that administer TRICARE.
TRICARE Information for Providers: The TRICARE website offers general information on rates and reimbursement.
TRICARE Program Manuals (2015 Edition): These manuals are applicable to the east and west regional managed care support contractors.
TRICARE Allowable Charges Tool: This interactive tool allows you to enter a zip code to find the maximum charges TRICARE is allowed to pay for the most frequently used procedures or services in a specific geographic area. These charges are tied by law to Medicare's allowable charges, and they do not reflect TRICARE beneficiary out-of-pocket cost shares, copayments, deductibles, or payments made by any other health plan coverages.