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.

You may submit a claim yourself for the following situations

• From a non-network provider for services performed in a doctor’s office, such as injections, immunizations, casting broken arms, etc. 
  For specialty pharmacy items administered at the doctor’s office (this might include immunizations or allergy shots)
• For Durable Medical Equipment (DME) and supplies

You cannot submit the following

• Institutional charges, submitted by both network and non-network facilities, for services rendered at a facility and not a doctor’s office (they include ambulatory surgery, radiological services and lab work) 
• Claims for services performed by a network provider (all network providers are required to submit claims on your behalf to insure the best discount available)

Network providers

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

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%.