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Outpatient Prospective Payment System

TRICARE's Outpatient Prospective Payment System was implemented on May 1, 2009.

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Quarterly Updates

Payment Status by HCPCS Code

Ambulatory Payment Classifications (APCs) with Status Indicators (SIs) and Payment Rates

Payment Status Indicators

Payment Status by HCPCS Code - Drugs

Maternity Diagnosis

Restriction Lists

The age/sex lists represent codes that TRICARE recognizes as having age and or sex restrictions. The TRICARE contractors need to make sure their age and sex file matches what is on the list or it could result in TRICARE Encounter Data Records failing.

Age Restrictions

The age restriction list is intended to serve as a factor of consideration in the processing of TRICARE beneficiary claims.  While it provides valuable information to inform decision-making, it should be considered in conjunction with standard of care, healthcare delivery guidelines, and other relevant factors and not solely relied upon as the basis of approving or denying claims. 

Sex Restrictions

DHA/TRICARE no longer maintains sex restrictions as of April 1, 2024.

Annual Updates

OPPS Pricing Elements

Statewide Cost to Charge Ratios

Provider Information Updates

Zip to Wage Index Crosswalk

OPPS Provider File

Last Updated: April 08, 2025
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