A TRICARE network provider agrees to accept the rates and terms of payment specified in its agreement with Humana Military as payment for a covered service. Participating non-network providers who accept assignment on the claim agree to accept the TRICARE allowable charge as payment in full for a covered service. These providers may not bill TRICARE beneficiaries more than this amount for covered services. Both network and non-network providers can seek applicable copays and cost-shares directly from the beneficiaries.
Non-network providers who do not accept assignment or do not “participate” on a claim do not have to accept the TRICARE allowable charge and may bill patients for up to 15 percent above the TRICARE allowable charge. If the billed amount is less than the TRICARE allowable charge, TRICARE reimburses the billed amount.
If a TRICARE beneficiary has Other Health Insurance (OHI), the provider must bill the OHI first. After the OHI pays, TRICARE pays the remaining billed amount up to the TRICARE allowable charge for covered services. Providers may not collect more than the billed charge from the OHI (the primary payer) and TRICARE combined. OHI and TRICARE payments may not exceed the beneficiary’s liability.
Medicare’s balance-billing limitations apply to TRICARE. Noncompliance with balance-billing requirements may affect a provider’s TRICARE and/or Medicare status. Balance-billing limitations only apply to TRICARE-covered services.
Providers may not bill beneficiaries for administrative expenses, including collection fees, to collect TRICARE payment. In addition, network and participating non-network providers cannot bill beneficiaries for noncovered services unless the beneficiary agrees in advance and in writing to pay for these services up front. At that point, the provider is not obligated to file a claim to TRICARE if the TRICARE specific waiver is in place and the noncovered service is confirmed prior to the date of service.