DECEMBER 22, 2023 – Are you looking for a new doctor for yourself or your family? In your search, you may see terms like “TRICARE-authorized provider,” “network provider,” and “non-network provider.” Knowing what these terms mean can help you choose which provider you see.
A TRICARE-authorized provider is a provider approved by TRICARE to give health care services to beneficiaries.
“Before you get care from a civilian provider, it’s important to make sure the provider is TRICARE-authorized,” said Paul Wuerdeman, TRICARE Health Plan provider networks lead with the Defense Health Agency. “A provider must be TRICARE-authorized for TRICARE to pay any part of your claim.”
There are two types of TRICARE-authorized providers: network providers and non-network providers. Read on to learn about these providers and how to find providers near you.
Network providers
A network provider is any TRICARE-authorized provider that has signed an agreement with your regional contractor. Network providers have agreed to follow TRICARE’s policies and procedures. This means that they:
• Have agreed to the contracted rate as payment in full for covered services
• Won’t ask you pay amounts
• File claims for you
Do you live overseas? Network providers overseas also have an agreement with the TRICARE overseas contractor. However, network providers only agree to provide cashless and claimless services to those who have TRICARE Prime Overseas or TRICARE Prime Remote Overseas. If you have TRICARE Select Overseas, you may have to pay up front to get services or file your own claims when you see a network provider.
Non-network providers
A non-network provider is a TRICARE-authorized provider that doesn’t have an agreement with TRICARE.
There are two types of non-network providers:
• Participating providers accept the TRICARE-allowable charge as payment in full for covered services. This means you’ll only have to pay your cost-share when you see the provider. You also won’t have to file claims.
• Non-participating providers are typically the most expensive provider option. That’s because they haven’t agreed to accept the TRICARE-allowable charge. Instead, they can charge up to 15% more than the TRICARE-allowable charge. When you see a non-participating provider, you should expect to pay the provider up front. Then you’ll need to file a claim with TRICARE for reimbursement. Keep in mind that you won’t be reimbursed for your cost-share or any charges above the TRICARE-allowable charge.
You can see non-network providers if you have TRICARE Select, TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult Select. If you have TRICARE Prime Remote, you can use non-network providers if network providers aren’t available in your remote location.
If you’re enrolled in TRICARE Prime, you may see a non-network provider only if:
• You decide to use the point-of-service option, or
• Your regional contractor approves it because no other providers are available
How to find TRICARE-authorized providers
To find a network or non-network provider near you, you can use the Find a Doctor tool. You can also go to All Provider Directories.
Before you visit a non-network provider, check to see if they accept TRICARE patients. Non-network providers who have accepted TRICARE in the past may not always accept TRICARE.
Medicare and TRICARE For Life providers
Do you have TRICARE For Life? As outlined in the TRICARE For Life Handbook, you may get health care services from Medicare participating and Medicare non-participating providers. Go to Medicare.gov to find providers near you.
You can also get care from providers who have opted out of Medicare. But keep in mind that you’ll have significant out-of-pocket expenses when you get care from opt-out providers.
If you get services for which TRICARE For Life is the primary payer, you must visit TRICARE-authorized providers and facilities.
Avoid unexpected costs
Want to avoid surprise costs? Knowing the type of provider you’re seeing and your plan’s rules for getting care can help. Network providers typically have lower out-of-pocket costs than non-network providers. If you aren’t sure if you’re seeing a network or a non-network provider, ask before you get care.
Remember that some services from your provider may require a referral or pre-authorization. This depends on your health plan. Go to Book Appointments to learn how to get care with your plan.
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