UnitedHealthgroup will replace TriWest Healthcare Alliance as the managed care contractor for TRICARE West region effective April 1, 2013. With the transition, it is a good time for pediatricians to review TRICARE contracting and payment schedules so they can enhance their negotiating leverage with their managed care contractor.

TRICARE has partnered with three regional contractors to provide health care services and support to U.S. military members and beneficiaries. HealthNet manages provider networks and referrals, enrollment, claims processing and customer service for the North region and Humana does so for the South region (see sidebar).

By law, TRICARE is required to follow specific payment criteria similar to those of Medicare. Based on these criteria, the TRICARE/CHAMPUS maximum allowable charge (TMAC/CMAC) was developed. Most procedures are paid using the national allowable charge system, with amounts for each procedure adjusted to reflect the local costs of doing business. These locality adjustments are the...

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