TRICARE beneficiaries have many options for selecting health
care providers. Knowing their providers’ TRICARE category
can help beneficiaries make the right choice, and save them
money. TRICARE terms used in reference to providers include
"authorized," "participating," "non-participating,"
"network" and "non-network."
Types of Providers
TRICARE-Authorized Providers:
TRICARE-authorized providers must be licensed by their state,
accredited by a national organization (if one exists) and
meet other standards of the medical community. Additionally,
they must fall into one of the categories of health care centers
(facilities) or individual providers described below. The
TRICARE regional contractors must certify the providers’ authorized
status before they can pay for covered services received from
providers. TRICARE-authorized providers are issued a TRICARE
provider number that enables them to file claims to TRICARE
for services they provide to TRICARE beneficiaries. Beginning
Sept. 1, 2004, all Medicare-certified providers who are recognized
as a provider class under TRICARE are considered TRICARE-authorized
providers.
Individual TRICARE-Authorized Providers:
Individual TRICARE-authorized providers include: attending
physicians, certified nurse practitioners, clinical nurse
specialists (if approved in the state in which they work),
certified psychiatric nurse specialists, Christian Science
practitioners and nurses (if currently listed in the Christian
Science Journal), dentists (DDSs or DMDs), independent laboratories,
medical equipment and supply firms, most clinical psychologists
(with Ph.D.s or Psy.D.s), physician assistants, podiatrists
and optometrists.
Individual TRICARE-authorized providers may refer beneficiaries
for specialty care. TRICARE will cost share covered services
from the following types of providers (only if the referring
provider’s name is shown on the claim form): audiologists,
licensed practical nurses, mental health counselors, nurse
anesthetists, occupational therapists, pastoral counselors,
physical therapists, radiologists, registered nurses and speech
therapists.
TRICARE-Authorized Health Care Centers (Facilities):
TRICARE-authorized facilities include: hospitals, college
or university infirmaries, Medicare-certified skilled nursing
facilities (not including retirement homes or homes for the
aged) and Christian Science sanatoriums that are a part of
the First Church of Christ, Scientist. Also included are some
ambulatory surgery centers, some birthing centers, some residential
treatment centers and some special treatment centers.
Some facilities, such as outpatient rehabilitation facilities,
birthing centers, pain treatment facilities, mental health
clinics, residential treatment centers and eating disorder
clinics may not be TRICARE-authorized providers, or the services
they provide may not be covered benefits. Beneficiaries should
contact the regional contractor, a TRICARE service center
(TSC) or a local beneficiary counseling and assistance coordinator
(BCAC)) for assistance. A BCAC directory is available online
at www.tricare.osd.mil/beneficiary/beneficiary/BCACDirectory.htm.
Network Provider:
TRICARE network providers are those TRICARE-authorized providers
who enter a contractual agreement with the TRICARE regional
contractor to provide health care to TRICARE Prime or TRICARE
Extra beneficiaries. They agree to accept TRICARE negotiated
rates, which are usually less than the TRICARE maximum allowable
charge (TMAC), as the full fee for the services they render,
and they file claims for the beneficiaries.
Non-network Provider:
Non-network providers are those TRICARE-authorized providers
who do not have a contractual agreement with the TRICARE regional
contractor to provide care to TRICARE beneficiaries. Care
received from a non-network provider may result in expensive
point-of-service charges for TRICARE Prime beneficiaries and
higher cost shares for beneficiaries under TRICARE Standard.
There are two types of non-network providers:
1. Participating Providers: Providers who participate in
TRICARE (participation is also referred to as accepting assignment)
agree to accept the TRICARE allowable charge as the full fee
for services they render including the beneficiary’s cost-share
and deductible, if any. Individual providers may participate
on a case-by-case basis. Hospitals that participate in Medicare,
by law, must participate in TRICARE for inpatient care. For
outpatient care, hospitals may participate on a case-by-case
basis. A participating provider will normally file TRICARE
claims for beneficiaries.
2. Non-participating Providers: Non-participating providers
do not agree to accept the TRICARE allowable charge as the
full fee for services they render. A non-participating provider
may charge up to 15 percent above the TRICARE allowable charge
for services, and beneficiaries who receive care from non-participating
providers are responsible for those additional charges. A
non-participating provider may or may not file TRICARE claims
for beneficiaries. Beneficiaries may be responsible for paying
for the services from a non-participating provider first,
then for filing their own claims with TRICARE to receive reimbursement.
TRICARE will not provide reimbursement for the additional
charges above TRICARE allowable charge.
Receiving Care from Providers NOT Authorized by TRICARE:
Beneficiaries who choose to receive medical care from providers
who are not TRICARE-authorized may be responsible for all
billed charges. Providers who are interested in becoming a
TRICARE-authorized provider should contact a regional provider
relations representative:
TRICARE North – www.healthnetfederalservices.com
1-877-TRICARE (1-877-874-2273)
TRICARE South – www.humana-military.com
1-800-444-5445
TRICARE West – www.triwest.com
1-888-TRIWEST (1-888-874-9378)
For More Information:
Beneficiaries may determine if their provider participates
in TRICARE, or if their provider is authorized by TRICARE
by asking their provider, by contacting their regional contractor,
or by visiting the TRICARE Web site at www.tricare.osd.mil.