TRICARE Policy Manual

About this manual

This document outlines policies for healthcare resource sharing between the Department of Veterans Affairs/Veterans Health Administration and the Department of Defense/Defense Health Agency. It covers provider network agreements, claims processing, reimbursement methods, and pharmacy drug claims. The document is dated April 1, 2015, with a revision date of September 20, 2019.

Frequently asked questions

What is the effective date for TRICARE coverage of services provided by a network DVA/VHA medical facility?

The effective date is determined by the agreement between the DVA/VHA and the MCSC.

How are claims submitted by DVA/VHA medical facilities processed?

All claims will be submitted by the DVA/VHA medical facility and shall be processed as participating claims.

What is the reimbursement basis for services provided by DVA/VHA medical facilities?

Reimbursement shall be based on a percentage discount off the CHAMPUS Maximum Allowable Charge (CMAC), the state prevailing, Diagnosis Related Group (DRG), or other methodology such as per diems.

How are pharmacy drug claims processed for DVA/VHA medical facilities?

Pharmacy drug claims shall be processed in accordance with Chapter 8, Section 9.1, with no discount applied.