Important information
If a provider is not TRICARE-authorized/certified on the date services are rendered, the claim will deny. If the provider does not complete and submit certification paperwork, the beneficiary will be responsible for all charges.
In most cases, providers will submit claims on behalf of TRICARE beneficiaries for healthcare services. However, there are some instances in which you can submit your own claim. Please note that if services are received at a network emergency room facility, but the provider is out-of-network, you must submit the claim yourself.
All TRICARE claims are subject to TRICARE Maximum Allowable Charge (TMAC). Tied by law to Medicare’s allowable charges, TMAC is the maximum amount TRICARE will pay a doctor or other provider for a procedure, service or equipment.
Please note: ‘TMAC’ may also be referred to as CHAMPUS Maximum Allowable Charge or (CMAC).
All TRICARE-authorized providers meet TRICARE licensing and certification requirements and are certified by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers may include doctors, hospitals, ancillary providers (e.g., laboratories, radiology centers) and pharmacies that meet TRICARE requirements. If you see a provider that is not TRICARE-authorized, you are responsible for the full cost of care.
Network providers are contractually required to submit claims for beneficiaries for services rendered. Beneficiaries cannot file a claim themselves for services rendered by a network provider. Network providers may accept copay/cost-share from beneficiaries prior to services rendered (beneficiaries should not pay up-front for services rendered by a network provider unless it is their copay/cost-share).
Non-network providers do not have a signed agreement with TRICARE and are considered out-of-network.
There are two types of non-network providers:
Participating non-network providers
Participating non-network providers may choose to participate on a claim-by-claim basis. They have agreed to accept payment directly from TRICARE and accept the TMAC (less any applicable patient costs paid by beneficiary) as payment in full.
Nonparticipating non-network providers
For nonparticipating non-network providers, beneficiaries may have to pay up-front for services rendered and file their own claim. These providers have not agreed to file your claim. The providers also have a legal right to charge up to 15% above the TRICARE-allowable charge for services (beneficiaries are responsible for paying this amount in addition to any applicable patient costs).
Please note: If a provider is not TRICARE-authorized/certified on the date services are rendered, the claim will deny. If the provider does not complete and submit certification paperwork, the beneficiary will be responsible for all charges.
Non-participating providers can charge you up to 15% more than TMAC, known as balance-billing. If you use a non-participating provider, you will have to pay all of that additional charge up to 15%.
The milk bank used must be certified and accredited by the
TRICARE will reimburse for 90 breast-milk storage bags every 30 days. If you require more than 90 in a 30-day period, you will need a prescription or Certificate of Medical Necessity (CMN) from your doctor. If you buy bags in bulk, TRICARE can only reimburse at 90 bags every 30 days, and cannot pay for future dates of service.
Breast milk storage bags are typically packaged as 100 bags per single box. When submitting claims for breast milk storage bags, it is important to include the actual number of breast milk storage bags supplied to ensure proper reimbursement for the bags. For example, if 90 breast milk bags are supplied, include “90” on the claim form instead of “1” for box.
Replacement supplies cannot be billed on the same day as the breast pump. When purchasing a breast pump, you will receive a kit which includes all supplies, including an initial set of breast milk bags. TRICARE will reimburse one kit per birth event. Breast pump supplies can be ordered before delivery, starting at 27 weeks of pregnancy.
TRICARE covers Durable Medical Equipment (DME) when prescribed by a physician and includes, but is not limited to, items such as wheelchairs, CPAP machines, crutches, etc.
If you are submitting a claim for DME, you must include a prescription or a Certificate of Medical Necessity (CMN) from your provider*. The CMN must include the length of need (rent to own DME is based on a 15-month rental and CMN needs to show a 15-month length of need) and should be faxed to (608) 221-7542.
*Excludes breast milk storage bags
Claims for prescriptions filled through a pharmacy must be submitted to:
Express Scripts, Inc.
PO Box 52132
Phoenix, AZ 85072-2132
