As of Jan. 1, TRICARE will be going from three to
two U.S. stateside regions, and the TRICARE regional
contractors will change. The regional contractors are
responsible for customer and provider service (
including provider contracting),
claims processing and payment, and prior authorization for certain health care
The TRICARE North and South Regions will be
combined as the new East Region and will include Alabama, Arkansas, Connecticut, Delaware, the District
of Columbia, Florida, Georgia, Illinois, Indiana, Iowa
(Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri
(St. Louis area), New Hampshire, New Jersey, New
York, North Carolina, Ohio, Oklahoma, Pennsylvania,
Rhode Island, South Carolina, Tennessee, Texas (
excluding El Paso area), Vermont, Virginia, West Virginia
The TRICARE West Region remains unchanged
and includes Alaska, Arizona, California, Colorado,
Hawaii, Idaho, Iowa (excludes Rock Island arsenal
area), Kansas, Minnesota, Missouri (except St. Louis area), Montana, Nebraska, Nevada, New Mexico,
North Dakota, Oregon, South Dakota, Texas (
southwestern corner including El Paso), Utah, Washington
Also as of Jan. 1, the regional contractors will be Humana Military (East Region) and Health Net Federal
Services (West Region).
TRICARE providers should have or soon will be
receiving notification and new contracts from their new
regional contractors. Pediatricians will need to care-
schedules, as the regional contractor offered payment
rate may be less than the maximum allowable charges
The TRICARE Standard network (the basic TRI-
CARE health program) will be renamed the TRICARE
Select network. The name of the TRICARE Prime
network, a network exclusively for active duty service
members and their families, will remain unchanged.
While children with TRICARE Select will be able to
see any TRICARE-authorized pediatrician, children
with TRICARE Prime must see an in-network primary
care manager, usually at a military treatment facility.
TRICARE (formerly known as CHAMPUS) uses
the CHAMPUS maximum allowable charges (CMAC)
for the most frequently used procedures or services.
These charges are the maximum amounts TRICARE
is allowed to pay for each procedure or service and are
tied by law to Medicare’s allowable charges. In negotia-
tions, pediatric practices are advised to counter regional
contractor proposals to discount the TRICARE rate
and instead insist on payments at 100% of the CMAC.
Note that the presence of a CMAC rate does not
indicate coverage policy or payment approval but in-
dicates that a payment rate could be calculated for a
Current Procedural Terminology/Healthcare Common
Procedure Coding System code based on Medicare data
or TRICARE claims history. Additionally, the absence
of a CMAC rate does not indicate coverage policy or
payment denial but that a rate cannot be automatically
computed by TRICARE. In the absence of a CMAC
rate, the allowable charge for a covered service would
default to the negotiated amount with the regional con-
tractor. Fees for a particular procedure code within a
selected locality are available at http://bit.ly/2vIDr7R.
(See resources for information on accessing coverage
and payment policies and rates.)
The Academy continues to advocate for appropriate
coverage and payment of all medically necessary pe-
diatric services, including Bright Futures services, on
behalf of the dependents of U.S. military servicemen
and servicewomen. To report an issue
regarding TRICARE payment or cov-
erage, complete an AAP Hassle Factor
Form at http://bit.ly/2vsL7hd.
Dr. Berman is a member of the AAP
Committee on Child Health Financing.
• To see what’s covered under TRICARE, visit https://www.
• The TRICARE Reimbursement Manual provides the
methodology for pricing allowable services and items
and for payment to specific categories and types of
authorized providers. Visit http://bit.ly/2wkRR0p.
• To view the list of codes that are excluded from coverage
and are not payable under the TRICARE program, visit
• To learn how TRICARE requires specific National Drug
Codes and units for vaccine payment, and how your
practice may have been overpaid or underpaid by TRICARE
for vaccines, visit http://practicemanagementblog.
• For information on what TRICARE pays providers, visit
• For information on TRICARE program changes, visit