Clarification of the Home Infusion Process

There are services that can be paid in addition to the Home Health Agency Prospective Payment System (HHA-PPS) amount when the TRICARE beneficiary is receiving home health services under a Plan of Care. The Plan of Care is a medical treatment plan established by the treating physician with the assistance of the home health care nurse.

According to the TRICARE Policy Manual, Chapter 8, Section 7.1, TRICARE may cost-share medically necessary supplies and nutritional products when they are used as the primary source of nutrition. These include:

• Enteral nutritional therapy
• Parenteral nutritional therapy
• Oral nutritional therapy
• Medically necessary vitamins and minerals added to the nutritional solution
• Intraperitoneal nutrition (IPN) therapy when determined to be medically necessary treatment for individuals suffering from malnutrition as a result of end stage renal disease.

According to the TRICARE Reimbursement Manual, Chapter 1, Section 15, TRICARE reimburses drugs and biologicals at 95 percent of the average wholesale price (AWP).The unique HCPCS J-code will facilitate agency reporting requirements for future data analysis, while the NDC will be used in determining the drug’s AWP. Drugs that do not appear on the Medicare "J" code pricing file will also be priced using 95 percent of the AWP.

TRICARE will allow payment in addition to the prospective payment amount for drugs and biologicals administered by other than an oral method (i.e., drugs and biologicals that are injected subcutaneous, intramuscular, or intravenous) when:

• Prescribed by a physician or practitioner
• Approved by the FDA
• Reasonable and necessary for the individual patient.

Billing

Under the HHA-PPS, all HHAs need to bill all services furnished under a Plan of Care, and for medical and other health care services rendered outside a plan of care with revenue codes 32X or 33X. This includes the drugs/biologicals on a UB-04 (CMS Form 1500) and HCPCS National Level II Medicare "J" codes.

Consolidated billing is required for all home health services for beneficiaries under a home health Plan of Care authorized by a physician. The home infusion company and/or pharmacy delivering the medication for home administration may bill TRICARE directly using the CMS Form 1500 claim form with appropriate NDC or HCPCS coding. TriWest will allow either party to submit these claims, but will not allow duplicative billing.

Providers will be reimbursed for drugs/biologicals minus the appropriate cost-share/copayment and deductible (Refer to TRICARE Reimbursement Manual, Chapter 12, Section 2, Figure 12-2-1, for the specific deductible and cost-sharing/copayment provisions for services paid in addition to the HHA PPS amount). The cost of administering the drug is included in the charge for the visit billed under bill type 32X or 33X, as appropriate, and is not separately reimbursable.

For more information, refer to the TRICARE Web site at www.tricare.mil or call TriWest at 1-888-TRIWEST (888-874-9378).