Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

OMB Control Number: 0720-0017
Expiration Date: 7/31/2025

REIMBURSEMENT OF CAPITAL AND DIRECT
MEDICAL EDUCATION COSTS
Dear provider:

TRICARE authorizes regional contractors 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.
•

Any hospital subject to the TRICARE Diagnostic Related Groups (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.

•

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 direct medical education costs.

•

All amended requests as a result of a subsequent Medicare desk review, audit or appeal must be submitted
along with a copy of the Notice of Program Reimbursement (NPR) 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.

•

For more information, providers may reference the Department of Defense federal register.

Properly completed requests will be processed within 30 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.
Please be sure to include the following along with the two page request form:
1. All applicable S-3 worksheets for total TRICARE inpatient days, residents/interns and total inpatient days.
2. All applicable D Part I and D Part II worksheets or B Part II and B Part III worksheets Critical Access Hospital (CAH) for
capital costs.
3. All applicable B Part I worksheets for direct medical education costs.
4. Copy of the Notice of Program Reimbursement (NPR) letter for amended requests.
5. The request must contain a signature and the title of the signing official. A hospital official must sign the request for
reimbursement, certifying that the information is accurate and based upon the Medicare Cost Report.
Please refer to the attached line item instructions for the Medicare Cost Report references. If you have questions, please
send email to [email protected] with subject line “Question:...”

TRICARE East Region
Capital and Direct Medical Education Reimbursement
[email protected]
*TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

OMB Control Number: 0720-0017
Expiration Date: 7/31/2025

REIMBURSEMENT OF CAPITAL AND DIRECT
MEDICAL EDUCATION COSTS

All information provided on the request must correspond to the information reported on the hospital’s Medicare Cost Report.
1.

Hospital name

Name of hospital making request

2.

Hospital address

Street address, city, state and ZIP Code

3.

Mailing address

Please note: Reimbursement checks will be mailed to the billing/reimbursement address that we
have documented in your provider file. It is important to keep your provider file up-to-date to ensure
payments are received timely.

4.

TRICARE provider #

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

5.

NPI

The hospital’s National Provider Identification Number (NPI).

6.

Medicare provider #

The hospital’s six digit Medicare provider number

7.

Period covered

The hospital’s fiscal year must correspond to the Medicare cost reporting period (mm/dd/yyyy)

8.

Total inpatient days

Days provided to all patients in units subject to Diagnostic Related Groups (DRG) based payments swing
bed days should not be included unless a Critical Access Hospital (CAH) prior to 12/1/2009:
•
•
•

9.

Total TRICARE
inpatient days

Medicare Cost Report form CMS 2552-10, Worksheet S-3, Column 8, Line 14
Medicare Cost Report form HCFA 2552-96, Worksheet S-3, Column 6, Line 12
Medicare Cost Report form HCFA 2552-92, Worksheet S-3, Column 6, Line 8

Only include days which were inpatient days “allowed” for payment. Days which were determined to be not
medically necessary, days which TRICARE made no payment because Other Health Insurance (OHI) paid the
full allowable amount and any claims in which Medicare makes a payment TRICARE For Life (TFL) are not to be
included. The discharge date should be within the reporting period

9a. Total TRICARE active Days provided to patients who were active duty claims members (mm/dd/yyyy)
duty days
10. Total allowable
capital cost

Total allowable capital cost as reported on the Medicare Cost Report:
•
•

11. Total Allowable
DME Cost

Total allowable direct medical education cost on the Medicare Cost Report:
•
•

12. Residents/Interns

Medicare Cost Report form CMS 2552-10 Worksheet S-3, Part I, Column 9, Line 14
Medicare Cost Report form HCFA 2552-92 or 96 Worksheet S-3, Part I, Column 7, Line 12

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:
•
•
•

14. Reporting date

Medicare Cost Report form CMS 2552-10, Worksheet B, Part I, Columns 20-23, Lines 30-33, 34 and 35
if the cost report reflects intensive care unit costs, Lines 43, 50-76 and 88-93
Medicare Cost Report form HCFA 2552-92 or 96, Worksheet B, Part I, Columns 21-24, Lines 25-28, 29
and 30 if the cost report reflects intensive care unit costs, Lines 33, 37-63

Total full-time equivalents for residents/interns on the Medicare Cost Report:
•
•

13. Total inpatient beds

Medicare Cost Report form CMS 2552-10, Worksheet D, Part I, Column 3, Lines 30-33, 34 and 35 if
the cost report reflects intensive care cost, and Line 43 add to the figures from Worksheet D, Part II,
Column 1, Lines 50-76 and 88-93
Medicare Cost Report form HCFA 2552-92 or 96, Worksheet D, Part I, Columns 3 and 6, Lines 25-28,
29 and 30 if it reflects intensive care cost, plus Line 33 add to the figures from Worksheet D, Part II,
Columns 1 and 2, Lines 37- 63

Medicare Cost Report form CMS 2552-10, Worksheet S-3, Column 2, Line 14, minus any amount on Line 13
Medicare Cost Report form HCFA 2552-89 and 92, Worksheet S-3, Column 1, Line 8, minus any
amount on Line 7
Medicare Cost Report form HCFA 2552-96, Worksheet S-3, Column 1, Line 12, minus any amount on Line 11

Date the request for reimbursement is completed

TRICARE East Region
Capital and Direct Medical Education Reimbursement
[email protected]
*TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

OMB Control Number: 0720-0017
Expiration Date: 7/31/2025

REIMBURSEMENT OF CAPITAL AND DIRECT
MEDICAL EDUCATION COSTS
Please select:
■

Initial request

 Amended request (attach copy of Notice of Program Reimbursement letter for amended requests)

1. Hospital name: __________________________________________________________________________________________
2. Hospital address: ________________________________________________________________________________________
3. Mailing address:_________________________________________________________________________________________
4. TRICARE provider #: _____________________________________________________________________________________
5. National Provider Identifier (NPI): ________________________________________________________________________
6. Medicare provider #: _____________________________________________________________________________________
7. Period covered (mm/dd/yyyy) : _____________________________ – ____________________________________________
(Must correspond to Medicare cost reporting period.)
8. Total inpatient days: _____________________________________________________________________________________
(Attach the applicable S-3 worksheets from the corresponding Medicare Cost Report)
9. Total TRICARE inpatient days for dep/retirees: _____________________________________________________________
(Provided in units subject to Diagnostic Related Groups (DRG)-based payment. This is to be only days which were
“allowed” for payment. Days which were paid by Other Health Insurance (OHI) or which were determined to be not
medically necessary, and any claims that Medicare makes a payment TRICARE For Life (TFL) are not to be included).
9a. Total TRICARE inpatient days for active duty members claims: _______________________________________________
10. Total allowable capital costs: _____________________________________________________________________________
(Attach the applicable D Part I & II worksheets from the corresponding Medicare Cost Report or B Part II & B Part III if
Critical Access Hospital (CAH))
11. Total allowable (direct medical education) Costs: ___________________________________________________________
(Attach the applicable B Part I worksheets from the corresponding Medicare Cost Report)
12. Total full-time equivalents for residents/interns: ___________________________________________________________
(Attach the applicable S-3 worksheets from the corresponding Medicare Cost Report)
13. Total inpatient beds: _____________________________________________________________________________________
(Attach the applicable S-3 worksheets from the corresponding Medicare Cost Report)
14. Reporting date (mm/dd/yyyy): ____________________________________________________________________________

TRICARE East Region
Capital and Direct Medical Education Reimbursement
[email protected]
*TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

OMB Control Number: 0720-0017
Expiration Date: 7/31/2025

REIMBURSEMENT OF CAPITAL AND DIRECT
MEDICAL EDUCATION COSTS

TRICARE capital and direct medical education reimbursement form checklist
 All applicable S-3 worksheets for total TRICARE inpatient  All applicable D Part I and D Part II worksheets or B
days, residents/interns, and total inpatient days
Part II and B Part III worksheets CAH for capital costs
 All applicable B Part I worksheets for DME costs

 Copy of the Notice of Program Reimbursement (NPR)
letter for amended requests

 The request must contain a signature and the title of
the signing official

 The completed Page 1 of the TRICARE capital and
direct medical education reimbursement form and this
signature page

Note: If the applicable information is not received with the submitted request, the forms will be returned to the requestor
unprocessed, which may result in a delay of timely filing.
I certify the above information is accurate and based upon the hospital’s Medicare cost report submitted to HCFA. 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.
Signature: _______________________________________________________________

Title: ___________________________

Typed name: ____________________________________________________________

Phone: _________________________

Email: _____________________________________________________________________________________________________
Contact name: ___________________________________________________________

Title: ___________________________

Phone: _____________________________________________________________________________________________________

Email request to: [email protected]
OMB Control Number: 0720-0017
Expiration Date: 7/31/2025
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0720-0017, is estimated to average 1 hour 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 the burden estimate or burden reduction suggestions to the
Department of Defense, Washington Headquarters Services, at [email protected].
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.

TRICARE East Region
Capital and Direct Medical Education Reimbursement
[email protected]
*TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.