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
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.
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
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.