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TRICARE® Requirements for Inpatient Rehabilitation Facility Claims

Friday, March 22, 2019

TRICARE reimburses inpatient rehabilitation facilities (IRFs) on a per discharge basis, with rates based on factors such as patient-case mix, rehabilitation impairment categories and tiered case mix groups (CMGs). The rates may be adjusted based on the length of stay, geographic area and demographic group.

To be paid under the IRF Preferred Payment System (PPS), facilities must adhere to Centers for Medicare and Medicaid Services (CMS) 42 CFR 412 requirements and complete a Patient Assessment Instrument (PAI) upon admission and discharge, and supply the physician order for patient admission. This required data must be electronically encoded into a CMS-approved IRF-PAI software, such as jIRVEN, available for free at www.cms.gov > Medicare > Inpatient Rehabilitation Facility PPS > IRF-PAI.

The jIRVEN software allows IRFs to create an electronic IRF-PAI for each patient and produces a report with a distinct CMG number. The first character of the CMG number is an alphabetic character and indicates the comorbidity tier. The last four characters of the CMG number are numeric and represent the distinct CMG number. As of October 2018, TRICARE requires a CMG number on all IRF claims.

Visit our Claims Billing Tips page for additional information on submitting TRICARE claims.