How is the reimbursement under OPPS calculated?
Claims pass through edits for eligibility, benefits, and authorizations before a determination as to whether the services are subject to OPPS reimbursement. If subject to OPPS, the OCE assigns an APC. The TriWest claims processing system then applies deductibles and cost shares. If not subject to OPPS, alternative TRICARE reimbursement methodologies are used.
