Claims
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.
Disclaimer: Using non-network providers
Beneficiaries MUST submit claims:
- When they receive service within a network ER facility but the provider is out-of-network.
Beneficiaries can submit claims:
- 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.
Beneficiaries cannot submit:
- 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.
View your claims
Find information on how to file claims, appeals and grievances, check status of claims, how to view your electronic Explanation of Benefits (EOB) and more. Watch short tutorial
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DISCLAIMER
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).
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%. See TRICARE.mil/Costs/Cost-Terms for additional information.
Network authorized vs. non-network authorized providers
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. Find a list of TRICARE-authorized providers
There are two types of TRICARE-authorized 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 do not have a signed agreement with TRICARE and are considered out-of-network.
There are two types of non-network providers: participating and nonparticipating.
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.
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.
Your Explanation of Benefits (EOB) is now available online
When you register for beneficiary self-service, you will have the ability to view and print your TRICARE EOB, giving you access to your information anytime. Remember, your EOB is an itemized statement that shows what action TRICARE has taken toward your claims and is not a bill.
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