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COVID-19 and TRICARE Policy Updates: Investigational Drugs; Long-Term Care Reimbursement; Skilled Nursing Facility Stays

Tuesday, November 24, 2020

Please review these important TRICARE policy updates implemented in response to the COVID-19 pandemic.

Expanded Coverage of Treatment Use of Investigational Drugs
Effective Sept. 30, 2020, TRICARE may cover the treatment use of investigational drugs as a limited benefit. The drug must be U.S Food and Drug Administration (FDA)-approved and the treatment must be for a serious or life‐threatening case of COVID‐19 or associated condition. Additionally, the investigational drug must be administered in an FDA-approved setting.

Temporary Hospital Expansion Sites
Effective Sept. 3, 2020, temporary hospitals and freestanding ambulatory surgical centers (ASCs) that enroll with Medicare as hospitals under Medicare’s “Hospitals without Walls” initiative are exempt from institutional requirements for acute care hospitals. Temporary hospitals must be approved by the Centers for Medicare & Medicaid Services (CMS) and meet all criteria for Medicare coverage of inpatient or outpatient hospital services. Freestanding ASCs must provide contractors with their CMS approval letter recognizing them as a hospital. Submit this documentation to HNFS:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373

If your facility’s enrollment status changes, it will no longer be recognized as a hospital, effective the date of the status change.

Skilled Nursing Facility Three‐Day Prior Hospital Stay Requirement
Effective for skilled nursing facility (SNF) admission dates on or after Sept. 3, 2020, the requirement for a qualifying hospital stay of three consecutive days or more prior to a SNF admission is waived for the duration of the President’s national emergency for the COVID‐19 outbreak.

Temporary Payment Adjustment on Inpatient Claims for Individuals Diagnosed
with Coronavirus or COVID‐19
Reimbursement for inpatient claims for COVID-19/coronavirus patients admitted on or after Jan. 27, 2020, will reflect a 20% increase to the diagnosis-related group (DRG) weighted rate. This temporary payment adjustment applies for patients diagnosed with:

  • B97.29 (other coronavirus as the cause of diseases classed elsewhere) for discharges on or before March 31, 2020, or
  • U07.1 (2019‐nCoVacute respiratory disease) for discharges on or after April 1, 2020, through the duration of the COVID‐19 public health emergency period.

For admissions occurring on or after Sept. 1, 2020, claims eligible for the 20% adjustment factor must indicate a positive COVID‐19 laboratory test. Tests may be performed prior to or during the admission, and may be confirmed during a post-payment medical review.

Long-Term Care Hospital Reimbursement
Per the Coronavirus Aid, Relief, and Economic Security (CARES) Act, claims for long-term care hospital (LTCH) admissions on or after Jan. 27, 2020, through the COVID-19 public health emergency period, will be reimbursed at the LTCH prospective payment system (PPS) standard federal rate instead of the lower site-neutral payment rate.

Find additional information on COVID-19 and TRICARE on our COVID-19 resources page.


FAQ Reminder: Does TRICARE cover new COVID-19 related codes as they are introduced by CMS?
As with all new Current Procedural Terminology (CPT®) and Common Procedure Coding System (HCPCS) codes, TRICARE reviews them against policy to determine coverage. Our claims system is updated regularly to include added codes. Claims may be delayed to allow for appropriate code approval and system updates.