0720-0017_SAMPLE collection instrument_ DRG Reimbursement

TRICARE North Region
SUBJECT: Reimbursement of Capital and Direct Medical Education Costs
Dear Providers:
TRICARE/CHAMPUS authorizes Contractors of Managed Care Support Contracts to reimburse hospitals for
allowed Capital and Direct Medical Education costs. Reimbursement is subject to the following regulations
as outlined in the TRICARE Reimbursement Manual, effective 10/01/98.
1. Any hospital subject to the TRICARE DRG-based payment system, which wishes to be
reimbursed for Allowed Capital and Direct Medical Education costs, must submit a request for
reimbursement to the TRICARE Contractor.

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2. The initial request must be submitted on or before the last day of the twelfth month following the
close of the hospital’s cost-reporting period. The request must correspond to the hospital’s Medicare
cost- reporting period (dates and costs). Hospitals must submit their request forms and applicable
pages from their Medicare Cost Reports to the TRICARE Contractor. Those hospitals that are not
Medicare participating providers are to use October 1 through September 30 fiscal year for reporting
Capital and DME Costs.

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3. All amended requests as a result of a subsequent Medicare desk review, audit, or appeal must
be submitted along with a copy of the NPR (Notice of Program Report) and the applicable pages from
the amended Medicare Cost Report to the TRICARE Contractor within 30 days of the date the
hospital is notified of the change. Failure to promptly report the changes resulting from a Medicare
desk review, audit, or appeal is considered a misrepresentation of the cost report information. Such a
practice can be considered fraudulent, which may result in criminal/civil penalties or administrative
sanctions of suspension or exclusion as an authorized provider.

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4. For more information, providers may reference the Department of Defense Federal Register.
Properly completed requests will be processed within 30 to 45 days, based upon the information submitted
on the enclosed form. All providers must submit the applicable pages from their Medicare Cost Report
when requesting reimbursement from the Contractor. The request must contain a signature and the title of
the signing official. Please refer to the attached line item instructions for the Medicare Cost Report
references.
A hospital official must sign the request for reimbursement, certifying that the information is accurate and
based upon the Medicare Cost Report. If you have questions, please contact one of the following persons:
North 1
Ines Watson
(803) 763-4908
[email protected]

North 2
Penny Cross
(803) 763-6795
[email protected]
Jacqueline Marvin
(803) 763-6594
Work Leader
[email protected]
Sincerely,
Robin Cooper
Manager, PGBA Finance

TRICARE North Region
PGBA, LLC
EXPLANATION FOR REIMBURSEMENT OF TRICARE
CAPITAL AND DIRECT MEDICAL EDUCATION COST
All information provided on the request must correspond to the information reported on the hospital’s
Medicare Cost Report.
The name of the hospital making request

2. Address

The hospital street address, city, state and zip code

3. TRICARE Provider Number

The hospital’s TRICARE Provider Number. This should
correspond to the hospital’s tax identification number.

4. Medicare Provider Number

The hospital’s 6 digit Medicare Provider Number.

5. Period Covered

The hospital’s fiscal year must correspond to the
Medicare cost reporting period.

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1. Hospital Name

Total “Inpatient Days” provided to all patients in units
subject to DRG-based payments. Reference Medicare
Cost Report, HCFA 2552-96 Worksheet S-3, Part 1, line
12, column 6 or Medicare Cost Report CMS-2552-10
Worksheet S-3, Part 1, line 14, column 8
(Swing Beds days should not be included).

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6. Total Inpatient Days

Total “TRICARE Inpatient Days” provided in units subject
to DRG-based payment. (This is to be only days which
were “allowed” for payment. Therefore, days which were
determined to be not medically necessary and days
which TRICARE made no payment because of other
health insurance paid the full allowable amounts, are not
to be included. (The discharge date must be within the
reporting period.)

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7. Total TRICARE/CHAMPUS Inpatient Days

8. Total Allowable Capital Cost

Total allowable capital cost as reported on the Medicare
Cost Report. From the Medicare Cost Report, HCFA
2552-92 or 2552-96 add the figures from Worksheet D,
Part 1, Title XVIII, columns 3 and 6, lines 25-28, lines
29 and 30 if it reflects intensive care cost, plus line 33 to
the figures from Worksheet D, Part II, Title XVIII, Hospital
PPS, columns 1 and 2, lines 37-63.
From the Medicare Cost Report CMS-2552-10 add the
figures from Worksheet D, Part I, Title XVIII, column 3,
lines 30-33, lines 34 and 35 if the cost report reflects
intensive care unit costs, and line 43, to the figures from
Worksheet D, Part II, Title XVIII, Hospital PPS, column 1,
lines 50-76 and 88-93.

9. Total Allowable Direct Medical Education Costs

Total Allowable Medical Education Costs as reported on
the Medicare Cost Report. From the Medicare Cost
Report, HCFA 2552-92 or 2552-96 add the figures from

TRICARE North Region
PGBA, LLC
Worksheet B, Part I, columns 21 through 24, lines 2528, lines 29 and 30 if it reflects intensive care costs,
plus line 33 and 37-63.
From the Medicare Cost Report, CMS-2552-10 add the
figures from Worksheet B, Part I, columns 20-23, lines
30-33, lines 34 and 35 if the cost report reflects intensive
care costs, line 43, lines 50-76; and lines 88-93.
Notes: Medical Education reimbursement can only be
included if the hospital has a Medicare approved
teaching program and is a “Low Volume” provider.
Total full-time equivalents for residents/interns as
reported on the Medicare Cost Report. From the
Medicare Cost Report 2552- 92 or 2552-96 use
Worksheet S-3, Part I, line 12, column 7.

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10. Residents/Interns

The number of available beds during the period covered
by the Medicare Cost Report, not including beds assigned
to healthy newborns, custodial care, and excluding distinct
part hospital units as reported on the Medicare Cost
Report HCFA 2552-92, Worksheet S-3, Part 1, column 1,
line 8, minus any amount on line 7.

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11. Total Inpatient Beds

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From the Medicare Cost Report 2552-10 use Worksheet
S-3, Part I, line 14, column 9 (Total Interns & Residents).

From the Medicare Cost Report HCFA 2552-96,
Worksheet S-3, Part 1, column 1, line 12, minus any
amount on line 11.

From the Medicare Cost Report CMS 2552-10,
Worksheet S-3, Part 1, column 2, line 14, minus any
amount on line 13.

12. Reporting Date

MAIL REQUEST TO:

ADDRESS FOR FEDEX,
UPS AND AIRBORNE:

The date the request for Reimbursement is completed.

PGBA, LLC
PGBA Finance, AG-740
CAPITAL AND DIRECT MEDICAL EDUCATION REIMBURSEMENT
P.O. BOX 100245
COLUMBIA, SC 29202-3245
PGBA LLC
PGBA Finance, AG-740
CAPITAL AND DIRECT MEDICAL EDUCATION REIMBURSEMENT
2300 SPRINGDALE DR. BLDG. 2
CAMDEN, SC 29020 -1728

TRICARE North Region
PGBA, LLC

OMB control number: 0720-0017
Expiration: xx-xx-xxxx

The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the
Department of Defense, Washington Headquarters Services, [email protected] (0720-0017). Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE
ADDRESS.

RETURN TO:

PGBA, LLC
Attn: PGBA Finance AG-740
Capital and Direct Medical Education Reimbursement, PO Box 100245, Columbia, SC 29202-3245

TRICARE REQUEST FOR REIMBURSEMENT OF CAPITAL AND DIRECT MEDICAL EDUCATION COSTS
1. HOSPITAL NAME:__________________________________________________________________
2. HOSPITAL ADDRESS:_______________________________________________________________
3. TRICARE PROVIDER NUMBER:_______________________________________________________
4.

MEDICARE PROVIDER NUMBER:_____________________________________________________
PERIOD COVERED FROM:___________________________TO:____________________________
(Must correspond to Medicare cost-reporting period.)

6.

TOTAL INPATIENT DAYS: ___________________________________________________________

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5.

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(Provided to all patients in units subject to DRG-based payment)

7. TOTAL TRICARE INPATIENT DAYS FOR DEP/RETIREES::_________________________________
(Provided in units subject to DRG-based payment. This is to be only days which were “allowed” for payment. Days
which were determined to be not medically necessary are not to be included)

8.

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7a. TOTAL TRICARE INPATIENT DAYS FOR ACTIVE DUTY CLAIMS:___________________________ (Provided in
units subject to DRG-based payment. This is to be only days which were “allowed” for payment. Days which were
determined to be not medically necessary are not to be included)
TOTAL ALLOWABLE CAPITAL COSTS:__________________________________________________
(Must correspond with the applicable pages from the Medicare Cost Report)
9.

TOTAL ALLOWABLE DIRECT MEDICAL EDUCATION COSTS:_______________________________
(Must correspond with the applicable pages from the Medicare Cost Report)

10.

TOTAL FULL-TIME EQUIVALENTS FOR RESIDENTS/INTERNS:_____________________________

11.

TOTAL INPATIENT BEDS:____________________________________________________________

12. REPORTING DATE:_________________________________________________________________
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I certify the above information is accurate and based upon the hospital’s Medicare cost report submitted to CMS. The cost
report filed, together with any documentation are true, correct and complete based upon the books and records of the
hospital. Misrepresentation or falsification of any of the information in the cost reports is punishable by fine and/or
imprisonment. Any changes, which are the result of a desk review, audit, or appeal of the hospital’s Medicare cost report,
must be reported to the TRICARE contractor within 30 days of the date the hospital is notified of the change. Failure to report
the changes can be considered fraudulent, which may result in criminal/civil penalties or administrative sanctions of
suspension or exclusion as an authorized provider.
Initial Request
Official’s Signature:
Official’s Printed Name:

Amended Request
Official’s Title:
Phone:

Official’s Mailing Address:___________________________________________________________________