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.